An LPN/VN in a heart-failure clinic sees a 76-year-old man with chronic heart failure and type 2 diabetes. During the visit, he becomes lightheaded. His BP has fallen from 128/74 to 96/60 mmHg and HR has risen from 80 to 122/min over ten minutes. RR is 20/min, temperature 36.8°C and bedside glucose 118 mg/dL. He is awake and breathing spontaneously. The clinic authorizes this trained nurse to activate its urgent-response pathway and provide immediate basic safety care while the RN and prescriber assess him. Which action should the nurse take first?
- Continue routine follow-up because the glucose result means the lightheadedness does not need urgent evaluation.
- Stay with him, activate the clinic’s urgent response, and assess airway, breathing and circulation while help arrives.
- Record the new BP and HR, then continue the visit without notifying the RN or prescriber.
- Wait for the routine recheck in one hour before acting on the vital-sign changes.