A client with a history of peptic ulcer disease is admitted to the hospital. Initial assessment reveals that his blood pressure is 96/60 mm Hg, his pulse rate is 120 bpm, and he has vomited coffee-ground material. Based on this assessment, what is the nurse’s priority action?
1. Administer an antiemetic.
2. Prepare to insert a nasogastric (NG) tube.
3. Collect data regarding recent client stressors.
4. Place the client in a modified Trendelenburg position.
The nurse should prepare to insert an NG tube. The data collected provide evidence that the client is experiencing an upper gastrointestinal bleed secondary to a peptic ulcer. The client will be placed on nothing-by-mouth status and an NG tube will be inserted to provide gastric decompression and alleviate vomiting. Administering antiemetics is not a priority action for a client who is hypotensive and vomiting coffee-ground emesis. Assessment of client stressors is appropriate after emergency care has been provided and the client stabilized. A modified Trendelenburg position is inappropriate for clients who are vomiting.
CN: Reduction of risk potential; CL: Synthesize
小编寄语：In fact, always accompany you, is that great yourself.其实一直陪着你的，是那个了不起的自己。