A client with peptic ulcer disease is in the emergency department and reports the pain has gotten much worse over the last several days. The client's blood pressure when lying down was 122/80 mm Hg and when standing was 98/52 mm Hg
What action by the nurse is most appropriate?
a.
Administer ibuprofen (Motrin).
b.
Call the Rapid Response Team.
c.
Start a large-bore IV with normal saline.
d.
Tell the client to remain lying down.
ANS: C
This client has orthostatic changes to the blood pressure, indicating fluid volume loss. The nurse should start a large-bore IV with isotonic solution. Ibuprofen will exacerbate the ulcer. The Rapid Response Team is not needed at this point. The client should be put on safety precautions, which includes staying in bed, but this is not the priority.
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