A nurse is caring for a patient who has a diagnosis of GI bleed
During shift assessment, the nurse finds the patient to betachycardic and hypotensive, and the patient has an episode of hematemesis while the nurse is in the room. In addition to monitoring the patient's vital signs and level of conscious, what would be a priority nursing action for this patient?
A) Place the patient in a prone position.
B) Provide the patient with ice water to slow any GI bleeding.
C) Prepare for the insertion of an NG tube.
D) Notify the physician.
Ans: D
Feedback:
The nurse must always be alert for any indicators of hemorrhagic gastritis, which include hematemesis (vomiting of blood), tachycardia, and hypotension. If these occur, the physician is notified and the patient's vital signs are monitored as the patient's condition warrants. Putting the patient in a prone position could lead to aspiration. Giving ice water is contraindicated as it would stimulate more vomiting.
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