Difficulty: Medium
Average Score: 78%
Simulated
A client arrived via ambulance to the emergency department with a chief complaint of gastrointestinal bleeding for 2 hours. What will the triage nurse do first?
Correct answer
C
Rationale
The correct answer is C: Obtain vital signs. The first step in triaging a patient with gastrointestinal bleeding is to assess their vital signs to determine the severity of the situation. Vital signs, such as blood pressure, heart rate, respiratory rate, and oxygen saturation, provide crucial information about the patient's condition and help prioritize the level of care needed. This immediate assessment allows the triage nurse to identify any signs of shock or instability, guiding further interventions and treatment. Inserting an NG tube (choice A) or completing a head-to-toe assessment (choice D) can wait until the patient's vital signs are stable and the immediate risk is addressed. Asking about precipitating events (choice B) may provide important information but is not as urgent as assessing vital signs in this critical situation.