Question

Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems UNIT EIGHT 174 3. Vital signs are now blood pressure 86/60 mm Hg. pule 96 beats per minute, respirations 24 per minute, and temperature 97.6°F (36.4°C). What is the nurse's analysis of the new data? What are the nurse's CRITICAL THINKING Read the following case study and answer the questions. Mrs. Sheffield has just returned from surgery. She had a gas- troduodenostomy (Billroth I) procedure. She has a nasogas- tric (NG) tube, 1,000 ml of lactated Ringer solution infusing at 100 mL/hr via intravenous (IV) route, and a Foley catheter. She is nil per os (NPO). Her vital signs are stable: blood pres- sure 118/90 mm Hg. pulse 80 beats per minute, respirations 16 per minute, and temperature 98°F (36,6°C). Her abdomi- nal dressing is clean, dry, and intact. She is drowsy but easily aroused. After getting Mrs. Sheffield settled in bed, the nurse connects her NG tube to intermittent low-wall suction as or- dered by her health care provider (HCP) and adds another १ next steps? 4. What should the nurse tell the HCP? blanket for warmth. An hour later, the nursing assistant tells the nurse that Mrs. Sheffield is vomiting bright red blood. The nurse goes to her room and finds her lying on her side propped up on one arm vomiting into an emesis basin. Her NG suction catheter contains 250 mL of bright red drainage. Her dressing remains clean and dry. She is diaphoretic. 5. The HCP orders a stat hematocrit and hemoglobis 1. What should be the nurse's first response? electrolytes, and oxygen at 2 L/min via nasal canna The HCP also tells the nurse to get Mrs. Sheffield ad turNuff shesuctioN to return to surgery. What are the nurse's priority nursing actions? 2. What is the nurse's next action? REVIEW QUESTIONS-CONTENT REVIEW

can anyone help me with this?

Answer 1

1. Nurse will stop NG suction.

2. Next action will be to inform physician

3. Vitals suggest that patient was developing hypovolemic shock because of blood loss. Nurse action should be to start cold fluid replacement therapy.

4. Nurse should tell the physician that mrs. Sheffield is having gastrointestinal bleed and her vitals are demonstrating developing shock.

5. Nurse should start oxygen therapy

inform patient and family for reexploration surgery

initiate blood transfusion if required