A 70-year-old client is admitted to the hospital with a lower gastrointestinal bleed. After assisting the client back to bed, the nurse finds approximately 600 mL of frank red blood in the commode. The client is now pale and diaphoretic and reports dizziness. Which action should the nurse perform first?

Question

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Acute blood loss is a medical emergency, and the nurse needs to carry out interventions rapidly. Lowering the head of the bed or placing the client in the supine position maintains blood perfusion to the brain and other vital organs. This can be done quickly to help stabilize the client before performing other interventions. (Option A) Assessing and recording vital signs is appropriate and should be reported to the health care provider, but this is not the priority. (Option B) Monitoring hemoglobin and hematocrit levels is appropriate to assess the severity of blood loss and need for possible blood transfusion. Blood loss typically takes a few hours to reflect on the client's laboratory report; therefore, this is not the priority. (Option D) Ensuring IV access and continuing fluid administration is appropriate. This maintains fluid volume due to blood loss and corrects or reduces potential for hypovolemic shock. This can be done after lowering the head of the bed. Educational objective: A client with significant blood loss has a medical emergency, and interventions that will hemodynamically stabilize the client should take priority.

A 70-Year-Old Client Is Admitted to the Hospital with a Lower