ABCs And Emergency Priorities Practice Test

A 59-year-old with cirrhosis and esophageal varices suddenly vomits a large amount of bright red blood on the medical unit. Assessment: pale and diaphoretic; heart rate 132/min, blood pressure 84/48 mm Hg, respiratory rate 26/min, oxygen saturation 92% on room air; hemoglobin 7.2 g/dL (12–16). Which intervention should the nurse perform FIRST?

A 66-year-old with a history of deep vein thrombosis is hospitalized after hip surgery. The client suddenly reports shortness of breath and “impending doom.” Assessment: respiratory rate 30/min, oxygen saturation 85% on room air, heart rate 126/min, blood pressure 92/58 mm Hg; lungs clear to auscultation; labs: D-dimer 2.1 mg/L FEU (normal <0.5). Which intervention should the nurse perform FIRST?