Progressive Care Nursing Certification (PCCN) Practice Exam

What is the priority nursing action for a patient with upper GI bleeding who has become obtunded and has low hemoglobin levels?

1. Check for orthostatic changes and hold medications

2. Obtain intubation equipment and administer normal saline

3. Insert an NG tube and transfuse packed RBCs

4. Prepare for upper endoscopy and collaborate regarding a vasopressin infusion

The correct answer is: Obtain intubation equipment and administer normal saline

In the scenario involving a patient with upper GI bleeding who has become obtunded and has low hemoglobin levels, the priority nursing action focuses on ensuring the patient's airway is protected and managing fluid resuscitation. Obtunding indicates a decreased level of consciousness, which raises concerns about the patient's ability to maintain a patent airway. By obtaining intubation equipment, the healthcare team prepares to secure the airway if the patient's condition deteriorates further. In addition to this, administering normal saline is crucial for volume resuscitation due to potential hypovolemia caused by bleeding. The combination of these actions addresses both immediate life-threatening concerns: protecting the airway and correcting hemodynamic instability. While monitoring for orthostatic changes and holding medications may be relevant, they do not directly address the immediate need for airway management in a patient whose consciousness is altered. Inserting an NG tube and transfusing packed RBCs can be important actions but are not as immediate as ensuring the airway can be secured. Preparing for an upper endoscopy and discussing a vasopressin infusion are also significant but do not take precedence over the immediate priorities of airway protection and volume resuscitation in a potentially unstable patient.