Question:

A client with a history of peptic ulcer disease is admitted to the hospital. Initial assessment reveals that his blood pressure is 96/60 mm Hg, his pulse rate is 120 bpm, and he has vomited coffee-ground material. Based on this assessment, what is the nurse’s priority action? 

1. Administer an antiemetic. 

2. Prepare to insert a nasogastric (NG) tube. 

3. Collect data regarding recent client stressors. 

4. Place the client in a modified Trendelenburg position.

Answer:2

The nurse should prepare to insert an NG tube. The data collected provide evidence that the client is experiencing an upper gastrointestinal bleed secondary to a peptic ulcer. The client will be placed on nothing-by-mouth status and an NG tube will be inserted to provide gastric decompression and alleviate vomiting. Administering antiemetics is not a priority action for a client who is hypotensive and vomiting coffee-ground emesis. Assessment of client stressors is appropriate after emergency care has been provided and the client stabilized. A modified Trendelenburg position is inappropriate for clients who are vomiting. 

CN: Reduction of risk potential; CL: Synthesize

翻译

问题：

一位有消化性溃疡病史的病人住院。初步评估显示，他的血压为96/60毫米汞柱，脉搏率为120次/分，并呕吐了咖啡渣。根据这一评估，护士的优先行动是什么？

1.服用止吐药。

2.准备插入鼻胃管。

3.收集有关近期病人压力源的数据。

4.将病人置于头低脚高位。

答案：2

护士应准备插入鼻胃管。所收集的数据提供了证据，证明患者正在经历消化性溃疡继发的上消化道出血。将病人置于无口进食状态，并插入胃插管进行胃减压和减轻呕吐。对于患有低血压和呕吐咖啡粉呕吐的患者，服用止吐药不是优先考虑的措施。在提供紧急护理和患者稳定后，评估患者的压力源是合适的。头低脚高体位不适合呕吐的患者。

CN：降低潜在风险；CL：综合

小编寄语：In fact, always accompany you, is that great yourself.其实一直陪着你的，是那个了不起的自己。