The nurse is caring for a patient who is experiencing a new onset of gastrointestinal bleeding. In which order should the nurse assess this patient?

Question

Choice 1. Identify possible contributing factors, including medications.
Choice 2. Obtain vital signs, including orthostatic changes.
Choice 3. Place the acutely ill patient on a cardiac monitor and obtain a rhythm strip.
Choice 4. Evaluate mental status.
Choice 5. Assess peripheral pulse strength, color, temperature, and cap refill of extremities.
Choice 6. Obtain oxygen saturation level.

Answer 1

Correct Answer: 1, 2, 3, 6, 5, 4

It is imperative to first assess for possible contributing factors. Obtaining vital signs and orthostatic vital signs can assess for early signs of hypovolemia. Placing the patient on a monitor and obtaining a rhythm strip help determine if arrhythmias are present. The oxygen saturation level helps determine if the body is being adequately oxygenated. Assessing peripheral pulse strength, color, temperature, and cap refill of extremities is part of the head-to-toe physical assessment. Evaluation of mental status, including level of consciousness and orientation, may provide clues to the extent of the hemorrhage and its effect on the oxygen-carrying capacity of remaining red blood cells.