The nurse is caring for a client with massive gastrointestinal bleeding from a gastric ulcer who received 6 units packed red blood cells (PRBCs) and 2 units fresh frozen plasma (FFP). The most recent laboratory results are a hemoglobin of 8.0 g/dL (4.96 mmol/L), platelets of 82,000/mm3 (82 X 109/L), a prothrombin time (PT) of 11.1 seconds, an international normalized ratio (INR) of 1.9, and a partial thromboplastin time (PTT) of 58 seconds. Vital signs are a heart rate of 110 beats/minute, respirations of 24 breaths/minute, a blood pressure of 80/50 mm Hg, and an oxygen saturation of 94% on 4 L/minute oxygen via nasal canula. Which intervention should the nurse implement first?

Reference Range:

• Hemoglobin [14 to 18 g/dL (8.69 to 11.17 mmol/L)]
• Platelets [150,000 to 400,000/mm3 (150 to 400 x 109/L)]
• Prothrombin time (PT) [11.0 to 12.5 seconds]
• International Normalized Ratio (INR) [0.8 to 1.1]
• Partial Thromboplastin Time (PTT) [60 to 70 seconds]

A. Measure the client's abdominal girth. While tracking abdominal distension is useful, it does not address the underlying cause of the client's deterioration. Measuring girth should not delay immediate intervention for a potentially life-threatening condition.
B. Monitor the client's recent hemoglobin levels. A drop in hemoglobin would indicate internal bleeding, but waiting for lab results could delay necessary treatment. The client is already showing signs of early shock, requiring urgent medical intervention rather than just monitoring.
C. Prepare for nasogastric tube (NGT) insertion. An NGT may be needed for bowel obstruction or paralytic ileus, but the client's worsening condition suggests a more urgent issue, such as intra-abdominal hemorrhage. Addressing the potential bleeding takes priority over decompression.
D. Notify the healthcare provider (HCP) of the client's status. The client's tachycardia, tachypnea, cool pale skin, and worsening abdominal distension suggest early shock, likely due to postoperative internal bleeding or abdominal compartment syndrome. Immediate notification of the HCP ensures rapid assessment, diagnostic testing, and potential emergency intervention to prevent further deterioration.

A. Creatine kinase-MB (CK-MB). CK-MB is a cardiac enzyme that rises 3-6 hours after myocardial injury and was previously used to diagnose myocardial infarction (MI). However, it is less specific than troponin and can be elevated in skeletal muscle damage, making troponin the preferred biomarker for cardiac injury.
B. Serum glutamic pyruvic transaminase (SGPT). SGPT (also known as alanine aminotransferase [ALT]) is a liver enzyme and is not a primary marker for cardiac injury. While cardiac arrest and hypoxia can lead to liver damage, monitoring cardiac-specific markers is the priority in this scenario.
C. Lactate dehydrogenase (LDH). LDH is a nonspecific marker of tissue damage that can be elevated in cardiac, hepatic, renal, or other organ injuries. It is not cardiac-specific and is no longer used as a primary diagnostic tool for MI.
D. Cardiac troponin. Troponin (T and I) is the most specific and sensitive biomarker for myocardial injury. The presence of ST elevation in multiple leads suggests acute myocardial infarction (MI) as the cause of cardiac arrest. Troponin levels begin to rise within 2-3 hours, peak at 12-24 hours, and remain elevated for 7-10 days, making them the most important laboratory value to monitor for ongoing cardiac damage.