A patient becomes pale and sweaty while standing. The pulse is 126 beats per minute, and the patient says, “I feel faint.” Which action should the nurse take first?
Correct answer: A. Assist the patient to sit or lie down safely
- A. Assist the patient to sit or lie down safely
- B. Ask the patient to walk to improve circulation
- C. Repeat the temperature before intervening
- D. Leave the patient alone while obtaining supplies
Explanation
Safety is the immediate priority because the patient may fall from poor perfusion or presyncope. The nurse should support the patient into a safe position, then assess vital signs, level of consciousness, and possible causes.
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About Vital Signs and Monitoring
Vital signs include temperature, pulse, respiration, blood pressure, oxygen saturation and pain assessment. Coverage includes correct measurement sites and techniques, normal adult ranges, factors that alter readings, trends in patient observations, and the difference between an abnormal finding that needs reassessment and one requiring immediate reporting.
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