The nurse is providing care to a patient admitted with hematemesis and melena. Which of the following nursing diagnoses would be the highest priority for this patient?
1. risk for aspiration related to potential changes in level of consciousness
2. risk for altered nutrition, less than body requirements related to NPO status
3. risk for fatigue related to decreased oxygenation
4. risk for anxiety related to fear of bleeding
1
Rationale: The most important nursing diagnosis for the patient at this time is the risk for aspiration because it falls into the category of "airway, breathing, circulation.". The patient's risk for altered nutrition is important but not the most important, at this time. The patient may experience fatigue and other anemia-related signs and symptoms, but this is not the most important. Anxiety is important and should be monitored and treated appropriately however is not as important as the patient's risk for aspiration.
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