The nurse is caring for a patient who is admitted with gastrointestinal bleeding and whose blood pressure is 140/80 mm Hg, pulse 72 beats/minute, respirations 14 breaths/minute, and temperature 98.8°F (37.1°C)
What finding should be reported to the RN or physician immediately?
a. Pulse 78 beats/minute
b. Crampy abdominal pain
c. Blood pressure 104/68 mm Hg
d. Occult blood in the stool
ANS: C
Blood pressure 104/68 mm Hg is a significant drop from the patient's prior pressure and may indicate that the patient is going into shock. Prompt treatment is needed.
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