On admission, a patient with gastrointestinal bleeding had vital signs of a blood pressure of 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 registered nurse (RN) or physician immediately?
a. Pulse 78 beats/minute
b. Crampy abdominal pain
c. Occult blood in the stool
d. Blood pressure 104/68 mm Hg
ANS: D
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. A. This is a normal pulse. B. Crampy abdominal pain does not indicate acute distress. C. Occult blood in the stool would be expected in the patient with gastrointestinal bleeding.
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