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