# Situation: A 66-year-old man weighing 70 kg has coronary artery disease and takes aspirin and clopidogrel after a coronary stent was placed last year. He is brought to the emergency department after vomiting bright red blood twice and passing a black, tarry stool. His blood pressure is 88/54 mmHg and heart rate 122 beats/min; he is awake and anxious. His serum creatinine on arrival is 1.0 mg/dL (88 µmol/L). He is not vomiting at the moment, and his airway is clear. The provider has written the following orders. Which should the nurse carry out FIRST?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630126  
> language: ko  
> subject: Nursing Practice V — Care of Clients with Maladaptive Patterns of Behavior; Care of Clients with Life-Threatening Conditions, Acute Multi-Organ Problems, High Acuity and Emergency Situations

## 문제

Situation: A 66-year-old man weighing 70 kg has coronary artery disease and takes aspirin and clopidogrel after a coronary stent was placed last year. He is brought to the emergency department after vomiting bright red blood twice and passing a black, tarry stool. His blood pressure is 88/54 mmHg and heart rate 122 beats/min; he is awake and anxious. His serum creatinine on arrival is 1.0 mg/dL (88 µmol/L).

He is not vomiting at the moment, and his airway is clear. The provider has written the following orders. Which should the nurse carry out FIRST?

## 보기

1. Send blood for type and crossmatch
2. Insert two large-bore intravenous catheters **✔ 정답**
3. Give a proton pump inhibitor intravenously as a bolus
4. Prepare him for endoscopy within 24 hours

**정답: 2**

## 해설

With signs of hemorrhagic shock and a clear airway, the first need is access for rapid volume and blood replacement. Blood for type and crossmatch is drawn as the catheters are inserted, and the IV proton pump inhibitor and endoscopy follow once access and resuscitation are under way.

## 심화 해설

The patient presents with classic signs of hemorrhagic shock: a systolic blood pressure of 88/54 mmHg and tachycardia at 122 beats/min after two episodes of hematemesis and melena. The airway is clear and he is awake, so the immediate threat is circulatory collapse from acute blood loss, not airway compromise. In acute upper gastrointestinal bleeding, the first priority after confirming airway patency is to establish reliable venous access for rapid volume resuscitation .

Two large-bore intravenous catheters are needed because they allow simultaneous infusion of crystalloid and blood products at flow rates that a single small catheter cannot achieve. The patient weighs 70 kg, and hemorrhagic shock requires aggressive fluid replacement guided by the degree of hypotension and tachycardia. Blood for type and crossmatch is drawn at the same time the catheters are inserted; it is not a separate step that delays access. The sequence matters because laboratory testing cannot proceed without a blood sample, and the sample is most efficiently obtained during catheter placement .

Key point! The order of actions is determined by the physiology of shock: circulation is supported before the bleeding source is identified. Endoscopy is essential but comes after resuscitation, not before .

The intravenous proton pump inhibitor is an important pharmacologic intervention for suspected peptic ulcer bleeding, but it does not restore circulating volume. A bolus of PPI given before volume resuscitation addresses acid suppression, not the immediate hemodynamic instability. Pharmacologic therapy and endoscopic intervention are secondary to the restoration of intravascular volume in a patient with hypotension and tachycardia from active hemorrhage.

Preparing for endoscopy within 24 hours is appropriate for non-variceal upper GI bleeding, but endoscopy is performed only after the patient is hemodynamically stable. The timeline of 24 hours reflects a window for therapeutic endoscopy, not an emergency that precedes vascular access .

| Priority | Action | Rationale |
| --- | --- | --- |
| 1 | Insert two large-bore IV catheters | Immediate access for crystalloid and blood product resuscitation in hemorrhagic shock |
| 2 | Send blood for type and crossmatch | Drawn simultaneously with IV insertion; enables transfusion |
| 3 | Give IV proton pump inhibitor | Acid suppression for suspected ulcer; does not restore volume |
| 4 | Prepare for endoscopy | Diagnostic and therapeutic, but only after stabilization |

Tachycardia in this setting reflects hemorrhagic hypovolemia, not another cause. In a patient with coronary artery disease on dual antiplatelet therapy with aspirin and clopidogrel, the risk of significant bleeding is elevated, and the presence of melena confirms upper gastrointestinal hemorrhage . The serum creatinine of 1.0 mg/dL (88 µmol/L) indicates preserved renal function at presentation, but ongoing hypoperfusion can rapidly lead to acute kidney injury if volume is not restored promptly.

Watch out! Do not delay vascular access to obtain laboratory specimens or to administer medications. The blood sample for type and crossmatch is collected as the catheters are placed, making the insertion of two large-bore IVs the first independent nursing action.

## 임상 시나리오

Upper GI Bleeding with Shock: First Nursing ActionPrioritize circulation after airway is clear
With hemorrhagic shock (BP 88/54 mmHg, HR 122/min) and a clear airway, the first need is venous access for rapid volume and blood replacement.

Insert two large-bore IV catheters to allow simultaneous infusion of crystalloid and blood products at high flow rates.

CautionDraw blood for type and crossmatch during catheter insertion; do not delay access for lab testing. PPI and endoscopy follow resuscitation.

## 핵심 개념

- **Hemorrhagic shock** — Circulatory collapse from acute blood loss, marked by hypotension and tachycardia.
- **Large-bore IV catheter** — Venous access allowing rapid simultaneous infusion of crystalloid and blood products.
- **Type and crossmatch** — Blood testing for ABO/Rh type and compatibility before transfusion.
- **Proton pump inhibitor** — IV medication reducing gastric acid to stabilize clots in upper GI bleeding.
- **Melena** — Black, tarry stool indicating upper gastrointestinal bleeding.

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