Question

Nurse is caring for a patient who has portal HTN. The patient is vomiting blood mixed with food after a meal. Which of the following action should the nurse take first?

A. Check lab values for recent H&H levels
B. Establish peripheral IV line for possible transfusion
C. Call lab to obtain stat platelet count
D. Obtain vital signs

Answer 1

The first action a nurse should take for a patient with portal hypertension who is vomiting blood is to obtain vital signs to assess the severity of the situation and guide further treatment.

Step-by-step explanation:

When a patient with portal hypertension is vomiting blood mixed with food, this could be indicative of a potentially life-threatening condition such as esophageal varices which can rupture due to the increased pressure. The nurse's first priority should always be to assess and stabilize the patient's vital signs to determine the severity of the situation. Following the ABCs (Airway, Breathing, Circulation) principle of acute care, the nurse should first check the patient's respiratory status and then quickly obtain vital signs to evaluate circulation and blood pressure which can indicate the severity of the hemorrhage and guide further actions.

Once vital signs are obtained and if the patient is hemodynamically unstable, establishing a peripheral IV line for possible transfusion and checking lab values for recent hemoglobin and hematocrit (H&H) levels would be subsequent steps. A stat platelet count can be important in assessing coagulopathy but is not the immediate priority.