Difficulty: Medium
Average Score: 84%
Simulated
Passage / Scenario
Vital SignsBlood pressure 88/54 mmHg, heart rate 115 bpm, respiratory rate 22 breaths per minute, and oxygen saturation 94% on room air.
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.
Initial CBC results:
White Blood Cell Count (WBC): 15,000 cells/┬ÁL (4,000 - 11,000 cells/┬ÁL)
Hemoglobin (Hgb): 6.5 g/dl (12.0 - 16.0 g/dL)
Hematocrit (Hct): 33% (37% - 47%)
Platelet Count: 250,000 cells/┬ÁL (150,000 - 450,000 cells/┬ÁL)
A 55-year-old male patient presents to the emergency department with complaints of acute gastrointestinal (GI) bleeding. Which of the following are the most appropriate initial nursing interventions for this patient? (Select all that apply)
Correct answer
A,B,C,D
Rationale
A, B, C, D: Administering IV fluids addresses hypotension and tachycardia, preparing for a blood transfusion corrects severe anemia, monitoring hemoglobin and hematocrit assesses anemia severity, and a PPI helps control bleeding. Oral iron supplements are not suitable for acute bleeding.