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The nurse is working at a first aid booth for a spring training game on a hot day. A spectator comes in, reporting that he is not feeling well. Vital signs are temp 104.1 F, pulse 132 BPM, respirs 26 breaths/min, and blood pressure 106/66 mm Hg. He trips over his feet as the nurse leads him to a cot. What is the priory action of the nurse?

a. admin tylenol 650 mg orally
b. encourage rest, and reassess in 15 minutes
c. sponge the victim with cool water and remove his shirt
d. encourage drinking of cool water or sports drink

User TMan
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Final answer:

The nurse's priority action would be to sponge the victim with cool water and remove his shirt.

Step-by-step explanation:

The primary action of the nurse in this situation would be to c. sponge the victim with cool water and remove his shirt. This action is important because the patient has an elevated body temperature (hyperthermia) of 104.1 F, indicating a potential heat-related illness. By sponging the victim with cool water, the nurse can help to lower his body temperature and provide relief.

The priority action for the nurse when a spectator presents with a body temperature of 104.1 F, a pulse of 132 BPM, respirations at 26 breaths/min, and blood pressure at 106/66 mm Hg, should be to immediately start reducing the body temperature to prevent complications of hyperthermia. High body temperature can lead to an increasing heart rate and strength of contraction, and if not managed promptly, it can result in damage to the body's systems, specifically the central nervous system. Since the patient is exhibiting signs of heat-related illness, such as hyperthermia, the nurse's primary action should be to sponge the victim with cool water and remove their shirt (option c), initiating rapid cooling. Giving oral medications like Tylenol could be challenging if the patient is experiencing confusion or difficulty swallowing, and rest alone is not sufficient to reduce a high fever rapidly. Encouraging hydration with cool water or sports drinks is important but should be done after initiating cooling measures to ensure the patient's condition does not worsen.

User QAH
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