In the middle of the summer, a homeless individual is brought to the hospital. The patient reports feeling weak and faint and having a headache
The patient seems irritable and his skin is cool and clammy. Vital signs are: temperature 99.9°F, pulse 100 bpm, respirations 18/minute, blood pressure 108/60 mm Hg. What would be the appropriate action for the nurse to take?
a. Provide oral fluids.
b. Prepare the patient for a chest x-ray.
c. Provide acetaminophen (Tylenol) 500 mg orally.
d. Provide Ciprofloxin 400 mg IV.
ANS: A
The patient has the symptoms of heat exhaustion which occurs when the body loses so much water and electrolytes through heavy sweating that hypovolemia occurs. Fluid and electrolyte replacement are the priority for this patient. Chest x-ray is not required and is not the priority at this time. Tylenol for pain or elevated temperature is not the priority at this time. Antibiotics are not necessary; the elevated temperature is related to fluid and electrolyte loss.
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