A patient with a large gastrointestinal bleed is pale, clammy, and dizzy. The blood pressure is 82/48 mmHg, and the patient is becoming less responsive. What should the nurse do first?
Correct answer: A. Activate the emergency response and remain with the patient
- A. Activate the emergency response and remain with the patient
- B. Give the prescribed oral antiemetic and reassess
- C. Place the patient in a chair to improve lung expansion
- D. Ask the patient to walk to the bathroom for a stool sample
Explanation
The patient shows signs of haemorrhagic shock with deteriorating consciousness and severe hypotension. The nurse should summon urgent assistance, stay with the patient, and support airway and circulation while further treatment is arranged. Oral medication and ambulation are unsafe in this condition.
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About Clinical Judgement and Prioritisation
Clinical judgement links assessment findings, nursing knowledge and patient responses to a safe decision. Coverage includes ABCDE assessment, recognising actual or potential instability, prioritising airway, breathing and circulation, using urgency and risk rather than routine order, reassessing after intervention, and distinguishing a nursing priority from a medical diagnosis or a task that can wait.
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