Question

When caring for a client admitted with massive vomiting of blood, which finding would be of most concern to the nurse?

1. Hematocrit of 35%
2. Cool hands and feet
3. Heart rate 124 beats/minute
4. Stools positive for occult blood

Answer 1

The most concerning finding in a patient with massive vomiting of blood is a heart rate of 124 beats/minute, as this suggests potential circulatory shock due to significant blood loss and requires immediate treatment. The Correct Answer is Option. 3.

Step-by-step explanation:

When caring for a client admitted with massive vomiting of blood, the finding that would be of most concern to the nurse is a heart rate of 124 beats/minute. This elevated heart rate could be indicative of circulatory shock, particularly hypovolemic shock, caused by significant blood loss.

In hypovolemic shock, the patient can present with a rapid heart rate, a weak pulse, cool hands and feet, and other signs such as confusion and a decrease in urine output. These symptoms suggest that the circulatory system is struggling to maintain blood flow and adequately supply oxygen and nutrients to the body's tissues. Immediate treatment and intervention are critical to restore blood volume and prevent further deterioration.