The nurse obtains vital signs on a patient with gastrointestinal bleeding who has a large, dark red, foul-smelling stool. Which vital sign changes should the nurse report as indicative of early shock?
a. Normal blood pressure, tachycardia, and rapid respirations
b. Rise in diastolic blood pressure, bradycardia, and slow respirations
c. Decreasing systolic blood pressure, bradycardia, and slow respirations
d. Drop in diastolic blood pressure, bradycardia, and shallow respirations
ANS: A, B, C, D, E, F
The order of interventions and testing is guided by the stability of the patient. The order for interventions should be securing an airway, ensure breathing, monitor heart rate and blood pressure, apply pressure to bleeding wounds, assess level of consciousness, and prepare for x-rays and other diagnostic tests.