Question

A client is taken to the urgent care clinic after fainting while exercising at the gym. The client is weak, pale, and diaphoretic. Which intervention should the nurse implement first?

a. Check blood glucose level.
b. Auscultate heart sounds.
c. Offer an oral hydration drink.
d. Perform a 12-lead electrocardiogram.

Answer 1

The first intervention a nurse should implement for the client presenting with weakness, paleness, and diaphoresis is to check the blood glucose level. This action can quickly identify or rule out hypoglycemia and determine if further emergency interventions are necessary.

Step-by-step explanation:

The client's initial presentation of weakness, paleness, and diaphoresis suggests an acute medical condition such as hypovolemia or shock that requires immediate intervention. The first action a nurse should take is to check the blood glucose level to quickly rule out or confirm hypoglycemia as a cause of fainting, which is a common and rapidly reversible condition. Checking glucose levels is a simple and non-invasive procedure that can provide immediate information.

After assessing blood glucose, other interventions may follow based on the findings, including auscultating heart sounds, offering hydration, or performing a 12-lead electrocardiogram (ECG). However, the client's symptoms suggest a possible case of hypovolemic shock, as indicated by the low blood pressure, confusion, and complaint of thirst; hence, initiating fluid resuscitation might be warranted after immediate life-threatening causes have been ruled out.