Case Study 12 (Gastrointestinal Bleeding) - Prioritization, Delegation, an
Assignment
Study online at https://quizlet.com/_8ccj46
Mr. S, a 50-year-old man, has driven him-
self to the emergency department (ED)
after vomiting bright red blood twice with-
in the past 6 hours. He arrives alert and
oriented × 3 but appears anxious. He
is able to provide only a vague history
but admits to drinking "a few" last week-
end. He knows that he is "supposed to
stop drinking" and takes "something for
his stomach," but he cannot recall the
name of the medication. He reports in-
termittent dizziness and fatigue that has
been worsening over the past 2 days.
His skin is dry and pale. His abdomen is
slightly distended. He reports pain (4 on
a scale of 1 to 10) in the midepigastric
area. Capillary refill is prolonged, blood
pressure is 140/90 mm Hg, pulse rate
is 110 beats/min, respiratory rate is 24
breaths/min, and temperature is 99°F
(37.2°C).
•Fluid and electrolyte balance
What is the *priority* nursing concept to
consider in planning emergency inter-
•Vomiting of bright red blood is a sign
ventions for Mr. S?
of active bleeding. The patient's physical
assessment findings and vital sign val-
•Pain
ues are indicative of physiologic compen-
•Anxiety
sation for blood loss. Pain, anxiety, and
•Fluid and electrolyte balance
adherence can be addressed after the
•Adherence
patient is stabilized.
What are *priority* interventions to per-
form for this patient? *Select all that ap-
ply.*
•Prepare for endotracheal intubation
•Assist with central line placement
•Check stool for occult blood
•Administer supplemental oxygen
•Monitor vital signs and oxygen satura-
tion
•Monitor hemoglobin and hematocrit
, Case Study 12 (Gastrointestinal Bleeding) - Prioritization, Delegation, an
Assignment
Study online at https://quizlet.com/_8ccj46
•Administer supplemental oxygen
•Monitor vital signs and oxygen satura-
tion
•Monitor hemoglobin and hematocrit
•Use the ABCs (airway, breathing, and
circulation) to prioritize. The patient
shows no overt signs of respiratory dis-
tress; however, there is a high risk for
hypovolemic shock, and supplemental
oxygen should be given based on the
assumption that the patient has already
sustained blood loss and therefore has
decreased oxygen-carrying capacity. Vi-
tal signs and oxygen saturation should
be monitored every 15 minutes for all un-
stable patients. Hemoglobin and hemat-
ocrit are obtained on arrival to establish
a baseline for comparison. The patient
does not need endotracheal intubation at
this point. In an emergency situation, pe-
ripheral IVs are usually established first
because central line placement is a ster-
ile procedure that takes more time. Even-
tually the stool should be checked for oc-
cult blood, but the presence or absence
will not affect the emergency treatment
decisions.
•Repeating measurement of vital signs
Which task is *most* appropriate to dele- •Repeating vital sign measurements falls
gate to the unlicensed assistive person- within the scope of the UAP's abilities.
nel (UAP)? The UAP (with training) can obtain blood
glucose levels and report them; howev-
•Repeating measurement of vital signs er, there is no indication that blood glu-
•Gathering equipment for nasogastric cose level should be checked every 2
hours. Gathering certain types of equip-
ment can be delegated; however, for NG
Assignment
Study online at https://quizlet.com/_8ccj46
Mr. S, a 50-year-old man, has driven him-
self to the emergency department (ED)
after vomiting bright red blood twice with-
in the past 6 hours. He arrives alert and
oriented × 3 but appears anxious. He
is able to provide only a vague history
but admits to drinking "a few" last week-
end. He knows that he is "supposed to
stop drinking" and takes "something for
his stomach," but he cannot recall the
name of the medication. He reports in-
termittent dizziness and fatigue that has
been worsening over the past 2 days.
His skin is dry and pale. His abdomen is
slightly distended. He reports pain (4 on
a scale of 1 to 10) in the midepigastric
area. Capillary refill is prolonged, blood
pressure is 140/90 mm Hg, pulse rate
is 110 beats/min, respiratory rate is 24
breaths/min, and temperature is 99°F
(37.2°C).
•Fluid and electrolyte balance
What is the *priority* nursing concept to
consider in planning emergency inter-
•Vomiting of bright red blood is a sign
ventions for Mr. S?
of active bleeding. The patient's physical
assessment findings and vital sign val-
•Pain
ues are indicative of physiologic compen-
•Anxiety
sation for blood loss. Pain, anxiety, and
•Fluid and electrolyte balance
adherence can be addressed after the
•Adherence
patient is stabilized.
What are *priority* interventions to per-
form for this patient? *Select all that ap-
ply.*
•Prepare for endotracheal intubation
•Assist with central line placement
•Check stool for occult blood
•Administer supplemental oxygen
•Monitor vital signs and oxygen satura-
tion
•Monitor hemoglobin and hematocrit
, Case Study 12 (Gastrointestinal Bleeding) - Prioritization, Delegation, an
Assignment
Study online at https://quizlet.com/_8ccj46
•Administer supplemental oxygen
•Monitor vital signs and oxygen satura-
tion
•Monitor hemoglobin and hematocrit
•Use the ABCs (airway, breathing, and
circulation) to prioritize. The patient
shows no overt signs of respiratory dis-
tress; however, there is a high risk for
hypovolemic shock, and supplemental
oxygen should be given based on the
assumption that the patient has already
sustained blood loss and therefore has
decreased oxygen-carrying capacity. Vi-
tal signs and oxygen saturation should
be monitored every 15 minutes for all un-
stable patients. Hemoglobin and hemat-
ocrit are obtained on arrival to establish
a baseline for comparison. The patient
does not need endotracheal intubation at
this point. In an emergency situation, pe-
ripheral IVs are usually established first
because central line placement is a ster-
ile procedure that takes more time. Even-
tually the stool should be checked for oc-
cult blood, but the presence or absence
will not affect the emergency treatment
decisions.
•Repeating measurement of vital signs
Which task is *most* appropriate to dele- •Repeating vital sign measurements falls
gate to the unlicensed assistive person- within the scope of the UAP's abilities.
nel (UAP)? The UAP (with training) can obtain blood
glucose levels and report them; howev-
•Repeating measurement of vital signs er, there is no indication that blood glu-
•Gathering equipment for nasogastric cose level should be checked every 2
hours. Gathering certain types of equip-
ment can be delegated; however, for NG
