A 46-year-old female patient presents to the emergency department with acute adrenal insufficiency and the following vital signs: P 118 beats/min, R 18 breaths/min, BP 83/44 mm Hg. pulse oximetry 98%. and T 98.8 F oral.
Which nursing intervention is the highest priority for this patient?
Administering furosemide (Lasix)
Replacing potassium losses
Providing isotonic fluids
Restricting sodium.
The Correct Answer is C
The patient's vital signs suggest that she is experiencing hypotension, tachycardia, and possibly dehydration due to acute adrenal insufficiency. The highest priority nursing intervention for this patient is to provide isotonic fluids to restore intravascular volume and blood pressure. This will also help to correct any electrolyte imbalances that may be present. Administering furosemide (Lasix) or replacing potassium losses may be necessary interventions, but they are not the highest priority at this time. Restricting sodium would be contraindicated in this situation as the patient is hypotensive and needs fluids to increase intravascular volume.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The most helpful finding by the nurse in determining whether a 67-yr-old patient with benign prostatic hyperplasia has an upper urinary tract infection (pyelonephritis) would be
**costovertebral tenderness**⁴. This is because costovertebral tenderness is a common symptom of pyelonephritis⁵. Pyelonephritis is an infection of the upper urinary tract that can cause fever, chills, flank pain, nausea, vomiting, and costovertebral tenderness⁵. Foul-smelling urine and bladder distention are not specific symptoms of pyelonephritis⁵. Suprapubic discomfort can be a symptom of lower urinary tract infection⁵.
Correct Answer is D
Explanation
Yes, that's correct. Insulin lispro (Humalog) is a rapid-acting insulin, which means it begins to work quickly after injection, usually within 15 minutes, and it peaks in about 1 to 2 hours. It typically lasts for 3 to 4 hours in the body.
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