# A nurse is caring for a client with peptic ulcer disease who suddenly begins vomiting bright red blood. The client's blood pressure drops from 130/80 mmHg to 90/60 mmHg, and the heart rate increases from 78 bpm to 120 bpm.

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## 문제

A nurse is caring for a client with peptic ulcer disease who suddenly begins vomiting bright red blood. The client's blood pressure drops from 130/80 mmHg to 90/60 mmHg, and the heart rate increases from 78 bpm to 120 bpm.

## 보기

1. Administer prescribed proton pump inhibitor intravenously
2. Insert a nasogastric tube to assess the amount of bleeding
3. Place the client in Trendelenburg position to improve circulation
4. Establish large-bore IV access and initiate fluid resuscitation **✔ 정답**

**정답: 4**

## 해설

In acute upper GI bleeding with hypovolemic shock signs (hypotension, tachycardia), priority is establishing large-bore IV access and initiating fluid resuscitation to restore circulating volume. Other options are secondary or contraindicated.

## 심화 해설

Clinical Priority for Acute Upper GI Bleeding with Hemodynamic Instability

The client’s presentation—sudden hematemesis of bright red blood accompanied by a significant drop in blood pressure (from 130/80 mmHg to 90/60 mmHg) and compensatory tachycardia (from 78 bpm to 120 bpm)—signals a transition from a stable peptic ulcer to an acute, massive upper gastrointestinal (GI) hemorrhage with decompensated hypovolemic shock. In the NCLEX-RN framework, this scenario falls under the Physiological Integrity category, specifically the sub-category of Physiological Adaptation and Reduction of Risk Potential. The core of the question tests the nurse's ability to prioritize interventions using the ABC (Airway, Breathing, Circulation) framework and clinical judgment. In hemorrhagic shock, the immediate threat to life is inadequate tissue perfusion due to the loss of circulating blood volume. The priority is to restore that volume to maintain oxygen delivery to vital organs.

Evidence-based protocols for acute GI hemorrhage emphasize that hemodynamic stabilization through fluid resuscitation is the foundational, non-negotiable first step in management [1]. The synthesis of evidence by Chen et al. (2026) explicitly frames fluid resuscitation not merely as a supportive measure, but as the critical intervention required to stabilize the patient before any diagnostic or therapeutic procedures can be safely undertaken [1]. This principle is reinforced by Wang et al. (2026), who identify prompt fluid resuscitation as a central nursing role in the emergency care of hypovolemic shock, with the immediate goal of restoring intravascular volume to improve cardiac output and oxygen delivery [2]. The choice of fluid type is a secondary consideration to the urgency of establishing access and starting volume replacement. While a network meta-analysis by Aldian et al. (2025) explores the comparative effectiveness of crystalloids versus colloids in hemorrhagic shock, its primary conclusion is that robust evidence to recommend one fluid type over another is lacking, which underscores that the act of initiating resuscitation itself is the critical priority, not the specific fluid selection [3].

Analyzing the other options through this lens clarifies why they are secondary or incorrect. Administering a prescribed proton pump inhibitor (Option 1) is an important pharmacological intervention for peptic ulcer disease, as it promotes clot stability by neutralizing gastric acid. However, it does not address the immediate, life-threatening circulatory collapse. In the NCLEX prioritization framework, a medication that treats the underlying cause is a lower priority than an intervention that treats the immediate, lethal consequence (shock). Inserting a nasogastric (NG) tube (Option 2) is a diagnostic and potentially therapeutic maneuver to assess the rate of active bleeding and clear the stomach for endoscopy. However, in an unstable patient, this procedure can induce vagal stimulation and worsen bradycardia, or cause further trauma; more importantly, it consumes valuable time without restoring perfusion. The patient's hemodynamic status must be stabilized first. Placing the client in Trendelenburg position (Option 3) is an outdated and potentially harmful practice for hypovolemic shock. This position does not improve circulation and can shift abdominal organs against the diaphragm, compromising respiratory function and increasing intracranial pressure. The correct nursing action is to place the client supine with legs elevated, but only after large-bore IV access is secured and fluid resuscitation is underway. Therefore, the immediate, evidence-based priority is to establish large-bore IV access and initiate fluid resuscitation to reverse the shock state and prevent progression to multi-organ failure [1,2].References (research sources)

- [1]Evidence-Based Fluid Resuscitation Protocol for Patients With Acute Gastrointestinal Hemorrhage: An Evidence Summary.Research articleChen Y, Dai L, Guo Q, Yang S. (2026) · DOI: 10.1177/00469580261435485

- [2]Best evidence for fluid resuscitation nursing in hypovolemic shock patients in emergency care based on GRADE system.Research articleWang Y, Lin J, Lin Y. (2026) · DOI: 10.2478/abm-2026-0009

- [3]Optimizing Fluid Resuscitation Strategies: A Network Meta-analysis of Effectiveness and Safety for Hemorrhagic Shock Patients in Emergency Settings.Meta-analysis/systematic reviewAldian FM, Visuddho V, Anggarkusuma MV, Wijaya JA, Lim AC, Chandrawira G, Sembiring YE, Semedi BP, Dillon JJ. (2025) · DOI: 10.5811/westjem.47198

## 임상 시나리오

Acute Upper GI Bleed with Shock: Immediate Nursing PriorityStabilize Circulation Before All Other Interventions
The primary goal is to restore tissue perfusion. For a patient with massive hematemesis and hypotension (90/60 mmHg), the first action is to establish large-bore IV access and begin rapid fluid resuscitation with crystalloids.

Other interventions like administering proton pump inhibitors or placing an NG tube are secondary. They are performed only after the patient is hemodynamically stable to prevent cardiovascular collapse.

CautionDo not place the patient in Trendelenburg position. This outdated practice does not improve circulation, may compromise breathing, and increases aspiration risk. Keep the patient supine.

## 핵심 개념

- **Esophageal Varices** — Esophageal varices. A condition where the veins in the lower esophagus become dilated and abnormally swollen due to portal hypertension caused by liver cirrhosis, etc. If ruptured, it can cause life-threatening massive bleeding.
- **Hematemesis** — Hematemesis. A symptom of vomiting blood due to bleeding in the upper gastrointestinal tract, such as the stomach or esophagus. Bright red blood suggests active bleeding, while coffee-ground material indicates slow or old bleeding.
- **Hypovolemic Shock** — Hypovolemic shock. Shock that occurs due to inadequate tissue perfusion caused by a sudden decrease in circulating blood volume. Causes include hemorrhage, dehydration, burns, etc. Early symptoms include tachycardia, hypotension, cold skin, sweating, and anxiety.
- **Large-bore IV Access** — Large-bore IV access. Generally refers to a thick venous catheter of 16 gauge (G) or larger. It must be secured as essential for rapid fluid and blood product transfusion in cases of massive hemorrhage or shock.
- **Fluid Resuscitation** — Fluid resuscitation. A treatment that rapidly supplies fluids such as normal saline or lactated Ringer's solution through a vein in cases of shock or dehydration to restore intravascular volume and promote hemodynamic stability.

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