What is your priority intervention as the nurse


Problem: A patients medical history includes; A- Fib, CHF, Hypertension, Shortness of Breathe on execution, Diabetes Mellitus Types 2. You walk into the patient s room to assess them and notice the laceration to the forehead is red, with noticeable drainage and warm to touch. Patient is complaining of nausea and vomiting and states she feels very lightheaded today. When asked, the patient states she has not had anything to eat or drink for the past 12 hours.  Patient denies any pain.  The vitals are as follows: B/P: 136/72, Heart Rate: 104, SPO2: 100% on room air. Temperature: 100.8F, RR: 16.  Based on this scenario, what is your priority intervention as the nurse? What is concerning about this patient and why? Explain the rationale behind your answers. What lab values should you assess on this patient and explain your reasoning for choosing each value you list?

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