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colleen colleen
wrote...
Valued Member
Posts: 17077
11 years ago
In a patient experiencing a GI hemorrhage, the focus of care is the effect of the bleeding on the cardiovascular status. Place in order the actions the nurse should take in assessing the patient.
Standard Text: Click and drag the options below to move them up or down.
Choice 1. Identify possible contributing factors including medications.
Choice 2. Obtain vital signs and orthostatic vital signs.
Choice 3. Place the acutely ill patient on a cardiac monitor and obtain a rhythm strip.
Choice 4. Evaluate mental status.
Choice 5. Assess peripheral pulse strength, color, temperature, and cap refill of extremities.
Choice 6. Obtain oxygen saturation level.
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Sunshine ☀ ☼

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Valued Member
11 years ago
It is imperative to assess for possible contributing factors. Obtaining vital signs and orthostatic vital signs can be an early sign of hypovolemia. Get the patient on a monitor and obtaining a rhythm strip to determine if arrhythmias are present. Obtain oxygen saturation to determine if the body is being adequately oxygenated. Assess peripheral pulse strength, color, temperature, and cap refill of extremities as part of the head to toe physical assessment. Evaluation of mental status including level of consciousness and orientation may provide clues to the extent of the hemorrhage and its effect on oxygen carrying capacity of remaining red blood cells.

Correct Answer: 1,2,3,6,5,4
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