Question

A client was transferred to the hospital unit as a direct admit. While the nurse is obtaining part of the admission history information, the client suddenly becomes semiconscious. Assessment reveals a systolic BP of 70, heart rate of 130, and respiratory rate of 24. What is the nurse's best initial action?

Lower the head of the client's bed.
Initiate an IV with a large bore needle.
Notify the physician of the assessment results.
Call for the cardiopulmonary resuscitation team.

Answer 1

The best initial action for the nurse when a patient becomes semiconscious with a low BP, high heart rate, and elevated respiratory rate is to promptly notify the physician of the assessment results, as the patient is showing signs of shock.

Step-by-step explanation:

When a patient is admitted to the hospital and suddenly becomes semiconscious with a systolic blood pressure (BP) of 70, heart rate of 130, and respiratory rate of 24, the nurse's best initial action is to notify the physician of the assessment results immediately. This patient is displaying signs consistent with shock, which is a medical emergency. Notifying the physician promptly is crucial for the rapid assessment and initiation of appropriate interventions, which may include fluid resuscitation and medications to support blood pressure and heart function. Other steps such as initiating an IV with a large bore needle may follow based on physician's order, but the top priority is alerting the healthcare provider to the critical nature of the patient's condition.