A nurse is preparing to perform an abdominal examination for a client who has a gastrointestinal disease. Identify the order in which the nurse should use the examination techniques. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Rationale:

A. Swelling of the lips: Swelling of the lips can be an early sign of anaphylaxis, a severe allergic reaction. Epinephrine is the first-line treatment for anaphylaxis because it rapidly reduces airway swelling, improves breathing, and supports blood pressure by constricting blood vessels.

B. Nausea: While nausea may occur during an allergic reaction, it is not a primary life-threatening symptom addressed by epinephrine. Epinephrine targets cardiovascular and respiratory symptoms more directly, not gastrointestinal discomfort.

C. Hand tremors: Tremors are actually a potential side effect of epinephrine due to its stimulation of the sympathetic nervous system. The medication is not intended to treat tremors and may even cause or worsen them temporarily.

D. Hyperglycemia: Epinephrine can increase blood glucose levels as a side effect, but it is not prescribed to treat or manage hyperglycemia. Managing blood glucose is not part of the therapeutic purpose of this emergency medication.

Rationale:

 • Obtain IV access is the first priority because the client is showing signs of hypovolemic shock low blood pressure (76/45 mm Hg), tachycardia (HR 121/min), pale mucous membranes, and diaphoresis likely due to GI bleeding. Immediate vascular access is necessary for resuscitation and fluid administration.

 • Call the surgical suite to notify that the client is arriving STAT would delay essential stabilization. Transporting an unstable client without securing IV access and fluid resuscitation could worsen their condition and is unsafe.

 • Place the client in a supine position with feet elevated (modified Trendelenburg) might temporarily improve venous return, but it does not address the underlying fluid deficit. It is not a substitute for urgent fluid replacement via IV access.

 • Recheck the client's oxygen saturation is not a priority because the client already has a stable oxygen saturation of 98% on room air. The immediate threat is circulatory collapse, not hypoxia.

 • Prepare to administer IV fluids follows IV access to treat hypotension and restore circulating volume. IV fluids help stabilize hemodynamics while awaiting further interventions like endoscopy or blood transfusion if needed.

 • Transport the client for endoscopy is inappropriate at this moment because the client is hemodynamically unstable. Endoscopy is important but must be delayed until the client is stabilized.

 • Check the ECG may be useful if cardiac concerns arise due to hypotension or tachycardia, but it does not take precedence over immediate circulatory support in this scenario.

 • Check arterial blood gases would not provide data that immediately changes the management. The client's O2 saturation is normal, and ABGs are not needed to diagnose or treat hypovolemic shock due to GI bleeding.