Question

After an acute episode of upper gastrointestinal (GI) bleeding, a client vomits undigested medications and reports severe epigastric and abdominal pain. The client has absent bowel sounds, rigid abdomen, a pulse rate of 134, and shallow respirations of 32 per minute. The primary healthcare provider has been contacted. What should be the nurse's next priority?

1. Keep the client nothing by mouth (NPO)
2. Teach the client coughing and deep breathing
3. Inquire whether any red or black stools have been noted
4. Place the client in the supine position with the legs elevated

Answer 1

The nurse should prioritize keeping the client nothing by mouth (NPO) due to potential acute abdominal distress and the possibility of a life-threatening condition that may require surgery.

Step-by-step explanation:

After an acute episode of upper gastrointestinal (GI) bleeding, the nurse's next priority for a client presenting severe epigastric and abdominal pain, absent bowel sounds, rigid abdomen, tachycardia, and tachypnea, would be to keep the client nothing by mouth (NPO). This client is likely experiencing acute abdominal distress, possibly peritonitis or another form of acute abdomen that could require surgery; hence, keeping the stomach empty is critical. In addition, the rigid abdomen and absent bowel sounds may indicate a life-threatening condition such as a perforated ulcer or bowel perforation where oral intake could exacerbate the client's condition. While waiting for further medical evaluation and intervention, other supportive measures would include closely monitoring vital signs, providing IV fluids as ordered, and preparing the client for potential urgent diagnostic tests or surgical intervention. Teaching coughing and deep breathing, inquiring about stool changes, and positioning would be secondary considerations and are not immediately critical.