On arrival in the emergency department, a patient who was in a motor vehicle accident is reported to be apprehensive, confused, hypotensive, tachycardic, and oliguric, with cool and clammy skin. What should the nurse do first?
a. Perform a rapid head-to-toe assessment.
b. Obtain patient's medical history from family.
c. Cover patient with warm blankets.
d. Reorient the patient to person, place, and time.
ANS: A
The priority is to assess the patient in shock quickly, starting with the Cs: airway, breathing, circulation, and disability.
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