Complete Question:
After an acute episode of upper gastrointestinal (GI) bleeding, a client vomits undigested antacids and reports having severe epigastric pain. The nursing assessment reveals an absence of bowel sounds, a pulse rate of 134, and shallow respirations of 32 per minute. In addition to calling the healthcare provider, what is the priority nursing action?
1) Prepare the client for surgery.
2) Administer oxygen per nasal catheter.
3) Place in the supine position, with legs elevated.
4) Ask the client if there have been any black stools.
Answer:
1) Prepare the client for surgery.
In addition to calling the healthcare provider, the priority nursing action is to prepare the client for surgery.
Explanation:
The symptoms that have been explained above are the symptoms of a type of ulcer called peptic or perforated ulcer.
Peptic or perforated ulcer occurs when there is a presence of holes or open sores in the walls (lining) of the stomach.
Perforated ulcer is caused by the consumption of highly acidic foods and beverages.
Some common symptoms include gastrointestinal bleeding, vomiting which could contain blood and pain in the stomach as well.
It is very important that the patient be taken in for surgery where the opening in the stomach lining can be closed.
The priority nursing action is to prepare the client for surgery.
This involves the use of operative manual and instrumental techniques on a person to investigate or treat a disease or injury.
Upper gastrointestinal (GI) bleeding and absence of bowel sounds means presence of holes in the tract which has to be operated on via surgery to increase chances of survival.
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