A 55-year-old male patient presents to the emergency department with complaints of acute gastrointestinal (GI) bleeding. The patient reports passing black, tarry stools and experiencing dizziness and weakness. On physical examination, he is pale and diaphoretic.
Which of the following are the most appropriate initial nursing interventions for this patient? (Select all that apply)
Administer IV fluids
Prepare for possible blood transfusion
Monitor hemoglobin and hematocrit levels
Administer a proton pump inhibitor (PPI)
Administer oral iron supplements to address anemia
Correct Answer : A,B,C,D
A. Administer IV fluids: The patient is hypotensive (blood pressure 88/54 mmHg) and tachycardic (heart rate 115 bpm), indicating possible hypovolemic shock due to blood loss. Administering IV fluids will help to stabilize blood pressure.
B. Prepare for possible blood transfusion: The patient's hemoglobin level is critically low (6.5 g/dL), indicating significant blood loss and severe anemia. Preparing for a blood transfusion is crucial to correct the anemia.
C. Monitor hemoglobin and hematocrit levels: Continuous monitoring of hemoglobin and hematocrit levels is vital to assess the severity of the patient's anemia and response to treatment, guiding further interventions.
D. Administer a proton pump inhibitor (PPI): PPIs can help reduce gastric acid secretion, which may help control bleeding from peptic ulcers, a common cause of upper GI bleeding.
E. Administer oral iron supplements to address anemia: Oral iron supplements are typically used for long-term management of iron deficiency anemia but are not effective for immediate correction of severe anemia, particularly in an acute setting with ongoing blood loss.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "Vomiting blood or material that looks like coffee grounds is a serious sign that I need to go to the emergency room." This is a correct understanding. Vomiting blood or coffee-ground material is a sign of gastrointestinal bleeding and requires immediate medical attention.
B. "If I experience severe abdominal pain, I should take an over-the-counter antacid and rest."
Taking an over-the-counter antacid without contacting a healthcare provider for severe pain could mask serious complications, such as recurrent bleeding or perforation, that need immediate medical attention. This statement indicates a need for further teaching.
C. "I should avoid taking NSAIDs like ibuprofen as they can increase my risk of bleeding." This is a correct understanding, as NSAIDs can cause or worsen gastric ulcers and increase the risk of bleeding.
D. "I should immediately report any black, tarry stools to my healthcare provider."This is a correct understanding. Black, tarry stools (melena) indicate upper gastrointestinal bleeding.
Correct Answer is ["A","B","C","D"]
Explanation
A. Administer IV fluids: The patient is hypotensive (blood pressure 88/54 mmHg) and tachycardic (heart rate 115 bpm), indicating possible hypovolemic shock due to blood loss. Administering IV fluids will help to stabilize blood pressure.
B. Prepare for possible blood transfusion: The patient's hemoglobin level is critically low (6.5 g/dL), indicating significant blood loss and severe anemia. Preparing for a blood transfusion is crucial to correct the anemia.
C. Monitor hemoglobin and hematocrit levels: Continuous monitoring of hemoglobin and hematocrit levels is vital to assess the severity of the patient's anemia and response to treatment, guiding further interventions.
D. Administer a proton pump inhibitor (PPI): PPIs can help reduce gastric acid secretion, which may help control bleeding from peptic ulcers, a common cause of upper GI bleeding.
E. Administer oral iron supplements to address anemia: Oral iron supplements are typically used for long-term management of iron deficiency anemia but are not effective for immediate correction of severe anemia, particularly in an acute setting with ongoing blood loss.
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