The nurse is working in a busy emergency department and is assigned 4 clients. Which client should the nurse see first?

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The client with a low body temperature and drowsiness needs immediate intervention to prevent and/or reverse physiologic compromise. Signs of hypothermia include a core temperature (eg, rectal) less than 95 F (35 C), mental status changes, shivering, and impaired coordination. Alterations in acid-base balance, coagulation values, and cardiac function may also occur. Hypothermia can lead to cardiac and respiratory failure and coma (Option D). Homeless clients are at higher risk for hypothermia from exposure to the elements, infections, and poorly managed chronic health conditions. The nurse should anticipate a workup for sepsis and various types of shock, in addition to environmental factors, while addressing this client's hypothermia. (Option A) Hemorrhagic cystitis (eg, bladder inflammation) is a well-known complication of cyclophosphamide (immunosuppressant and chemotherapy agent). The client is instructed to drink plenty of fluids. This client may need IV hydration and other preventive measures (eg, mesna therapy). Bleeding is usually minimal and occasionally requires a blood transfusion, but is rarely life threatening. (Option B) Nausea and vomiting are expected side effects after chemotherapy. This client needs IV access established (if the chemotherapy port cannot be accessed) to address the nausea and prevent dehydration. However, this client would not take priority. (Option C) This client needs to have all wounds cleaned and irrigated prior to suturing, but would not take priority. Educational objective: Hypothermia is a medical emergency that requires immediate intervention, including monitoring, rewarming, and supportive care. Hemorrhagic cystitis (eg, bladder inflammation) is a well-known complication of cyclophosphamide.

The Nurse Is Working in a Busy Emergency Department and Is