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 B
Explanation
Gas pains and abdominal distention are common postoperative complications following small bowel resection. Ambulation is a simple and effective nursing intervention that can help alleviate these symptoms. Walking helps stimulate peristalsis, which can help move gas and stool through the gastrointestinal tract. It can also help prevent postoperative complications such as pneumonia and deep vein thrombosis.
Administering morphine sulfate (option A) may relieve pain, but it can also worsen constipation and abdominal distention. Promethazine (option C) is an antiemetic medication and may be helpful if the patient is experiencing nausea, but it is not the best intervention for gas pain and abdominal distention. Instilling a mineral oil retention enema (option D) may also be helpful in some cases, but it is not typically the first intervention for these symptoms and should be ordered by a healthcare provider.

Correct Answer is C
Explanation
Lipase is an enzyme that is produced by the pancreas and is involved in the digestion of fats. In acute pancreatitis, the pancreas becomes inflamed, and lipase levels in the blood can become significantly elevated. Monitoring lipase levels can help healthcare providers to assess the severity of pancreatitis, track the effectiveness of treatment, and determine when it is safe to start a patient on a normal diet.

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