56-year female arrives at the emergency department (ED) after reporting persistent vomiting overnight, described as bright red blood. She reports mid-epigastric pain that is worsened when she eats. She rates the pain as an 8 out of 10, described as burning. Her bowel sounds are active in all four quadrants, and no abdominal distention was noted. She endorses nausea. She appears pale with dry skin. The client is alert and fully oriented. Her medical history includes osteoarthritis in her hips and knees, alcohol use disorder, hypothyroidism, and generalized anxiety disorder. She states that her knees have caused her so much pain that she has been less physically active for the past two weeks. She reports smoking one pack of cigarettes daily and drinking two glasses of red wine daily. Her current medications include daily use of naproxen, which she reports increased usage because of knee pain, levothyroxine, and citalopram. She recently started taking over-the-counter omeprazole three days ago for an unspecified reason.

Oral Temperature 98^o F (36.7^o C)

Pulse 107/minute

Respirations 19/minute

Blood pressure 101/68 mm Hg

Oxygen saturation 95% on room air

• Insert two peripheral vascular access devices
• Infuse two units of packed red blood cells
• Pantoprazole 40 mg, IV
• Morphine 4 mg, IV
• Insert nasogastric tube (NGT)