The nurse is caring for a patient who lost consciousness and collapsed. Which site will be used to determine if the patient has a pulse?

A. Document the findings in the patient's medical record. While documentation is important, further assessment is needed before determining if the blood pressure is abnormal for this patient.
B. Apply a cool washcloth to the patient's forehead. The patient’s temperature is normal (98.9°F), so there is no need for cooling measures.
C. Administer oxygen at 2 L/minute via nasal cannula. The pulse oximetry is 94%, which is adequate for most patients. Oxygen is not needed unless the patient shows signs of respiratory distress.
D. Ask the patient about his usual blood pressure results. The blood pressure (144/94 mmHg) is elevated, but before determining if intervention is needed, the nurse should ask if this is typical for the patient or if it is an isolated finding.

A. Remove fans to prevent premature chilling. While preventing rapid cooling is important in some cases, this action is not the priority. The patient’s symptoms suggest heat-related illness, which requires immediate assessment.
B. Apply a hyperthermia blanket to lower temperature slowly. Hyperthermia blankets are typically used in controlled environments for gradual cooling, but first, the patient’s temperature must be assessed to determine the severity of heat-related illness.
C. Take the patient's temperature and vital signs. Confusion and muscle cramps after working in heat suggest possible heat exhaustion or heatstroke, which can be life-threatening. Assessing temperature and vital signs is the priority to determine the severity and guide further treatment.
D. Place the patient in a tub of iced water. Ice water immersion is appropriate for severe heatstroke with a dangerously high core temperature, but cooling measures should only be initiated after confirming hyperthermia with a temperature assessment.