Question

An adult client is brought to the emergency department by a friend who states, "We were all partying at a club, and all of a sudden my friend collapsed." Vital signs revealed a temperature of 99.2° F, pulse of 152, respiratory rate of 32, blood pressure of 163/92. After performing a physical assessment and collecting a health history from the client, what action should the nurse take next?

1. Reassess the client and allow the friend to stay.
2. Inform the healthcare provider of the client's status and prepare to start an intravenous (IV) line.
3. Assign the client to a private room and put a cool cloth on the client's forehead.
4. Place the client in a dimly lit room and perform a neurologic assessment every 15 minutes.

Answer 1

The nurse should immediately inform the healthcare provider of the client's critical vital signs and prepare to start an IV line to address the potential life-threatening condition rapidly.

Step-by-step explanation:

When a client arrives at the emergency department with the symptoms described - a temperature of 99.2° F, pulse of 152, respiratory rate of 32, blood pressure of 163/92 - these vital signs suggest that the client may be experiencing a serious medical situation, such as shock or a drug overdose, particularly as the incident occurred at a club party where substances may have been involved. The first action a nurse should take would be option 2: inform the healthcare provider of the client's status and prepare to start an intravenous (IV) line. This is an urgent situation requiring immediate medical assessment and intervention due to signs of potential cardiac issues or other life-threatening conditions. Starting an IV provides a route for administering necessary medications and fluids quickly. While reassessment and a neurologic assessment are important, the priority is to stabilize the patient's condition and ensure that they are under medical supervision for further diagnosis and management.