QuestionAugust 15, 2025

The emergency department nurse is triaging a client whose spouse reports a sudden onset of symptoms to include fever, tremors,and decreased level of orientation.They also report psychotic behavior accompanied by tachycardia and palpitations.The only significant medical history of that the client is 4 days postoperative laparotomy appendectomy without complications and discharged home 2 days ago. Which intervention should the nurse do first? Initiate a large bore intravenous catheter. Perform a 12-lead electrocardiogram test. Insert an indwelling urinary catheter drainage system. Obtain serum electrolytes and kidney function test laboratory specimens.

The emergency department nurse is triaging a client whose spouse reports a sudden onset of symptoms to include fever, tremors,and decreased level of orientation.They also report psychotic behavior accompanied by tachycardia and palpitations.The only significant medical history of that the client is 4 days postoperative laparotomy appendectomy without complications and discharged home 2 days ago. Which intervention should the nurse do first? Initiate a large bore intravenous catheter. Perform a 12-lead electrocardiogram test. Insert an indwelling urinary catheter drainage system. Obtain serum electrolytes and kidney function test laboratory specimens.
The emergency department nurse is triaging a client whose
spouse reports a sudden onset of symptoms to include fever,
tremors,and decreased level of orientation.They also report
psychotic behavior accompanied by tachycardia and
palpitations.The only significant medical history of that the
client is 4 days postoperative laparotomy appendectomy
without complications and discharged home 2 days ago.
Which intervention should the nurse do first?
Initiate a large bore intravenous catheter.
Perform a 12-lead electrocardiogram test.
Insert an indwelling urinary catheter drainage system.
Obtain serum electrolytes and kidney function test laboratory
specimens.

Solution
4.4(258 votes)

Answer

Initiate a large bore intravenous catheter. Explanation 1. Identify the most urgent symptom The client exhibits fever, tremors, decreased orientation, psychotic behavior, tachycardia, and palpitations. These symptoms suggest a potential acute condition that requires immediate stabilization. 2. Determine priority intervention Initiating a large bore intravenous catheter is crucial for rapid administration of fluids or medications, which can stabilize the patient quickly in case of shock or severe dehydration.

Explanation

1. Identify the most urgent symptom<br /> The client exhibits fever, tremors, decreased orientation, psychotic behavior, tachycardia, and palpitations. These symptoms suggest a potential acute condition that requires immediate stabilization.<br /><br />2. Determine priority intervention<br /> Initiating a large bore intravenous catheter is crucial for rapid administration of fluids or medications, which can stabilize the patient quickly in case of shock or severe dehydration.
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