An elderly male patient, who has been experiencing abdominal pain, is admitted to the hospital from a long-term care facility. It has been a week since his last bowel movement, his abdomen is distended, and he recently vomited 150 mL of dark brown emesis. In what order should the nurse implement the following interventions? Arrange from the highest priority at the top to the lowest at the bottom.
Explanation & Rationale
Elevate the head of the bed (Choice A) Highest priority: reduces risk of aspiration from ongoing emesis, promotes ventilation, and immediately addresses airway/breathing safety. Complete a focused assessment (Choice C) Next priority: gather critical data on abdominal distension, bowel sounds, pain, emesis characteristics, and overall status to guide further interventions. Send the emesis sample to the lab (Choice B) After stabilizing and assessing, the nurse should send the sample for analysis (possible GI bleed, obstruction, or infection). This is important but not urgent compared to airway and assessment. Offer PRN pain medication (Choice D) Pain management is important, but it comes last because safety and diagnostic priorities must be addressed first.