Which patient does the emergency department nurse assess first?

During a comprehensive physical assessment, the nurse instructs the patient to stand still with the eyes closed. After a few seconds, the patient begins to sway and the nurse guides the patient into the chair. How does the nurse document this finding?

A septic patient begins to ooze blood from around intravenous cannulation sites and from the gums. The patient’s urine has turned from concentrated yellow to brown. Upon further assessment, the nurse notes the patient’s right calf is swollen, red, and painful. The nurse anticipates which laboratory abnormalities in this patient? Select all that apply.