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Nurses’ Notes 1200 Client presents to urgent care today with recent onset of nausea and vomiting over the last 12 hours. Reports not being able to take in any foods or fluids without vomiting. Denies abdominal pain, diarrhea, or constipation. Borborygmus on auscultation. Left lower quadrant tenderness on palpation. Abdominal distension was noted. Vital signs: blood pressure, 112/87 mm Hg; heart rate, 83 beats/min; respiratory rate, 15 breaths/min; oxygen saturation, 97% on room air; temperature, 98.7°F (37.1°C). Hemoglobin: 12.5 g/dl (125 g/l); hematocrit: 40% (0.40). 1225 Called into room by the client after another episode of vomiting that “looked funny.” Approximately 420 ml of coffee-ground appearance of emesis on assessment. Vital signs: blood pressure, 89/67 mm Hg; heart rate, 112 beats/min; respiratory rate, 21 breaths/min; oxygen saturation, 96% on room air. Hemoglobin: 9 g/dl (90 g/l); hematocrit: 37% (0.37). Provider informed. The nurse is performing a full assessment after the 1225 episode of coffee-ground emesis. Which assessment finding(s) requires immediate follow-up?
SCIENCE
HEALTH SCIENCE
NURSING

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