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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Prochlorperazine is an antiemetic medication that is commonly used to treat nausea and vomiting caused by various conditions, including chemotherapy, radiation therapy, and surgery. Giving the medication before the dressing changes, can prevent or minimize the onset of nausea and vomiting, which can be triggered by the pain and anxiety associated with the procedure.

Option B, keeping the patient NPO (nothing by mouth) for 2 hours before dressing changes, may be helpful in reducing the risk of aspiration if the patient needs sedation or general anesthesia for the procedure. However, it is not directly related to reducing the patient's nausea.

Option C, avoiding performing dressing changes close to the patient's mealtimes, may help reduce the risk of nausea caused by an overly full stomach, but it is not directly related to reducing the patient's nausea during the procedure.

Option D, administering prescribed morphine sulfate before dressing changes, may help reduce the patient's pain during the procedure, but it may also increase the risk of nausea and vomiting as a side eﬀect. Therefore, this option may not be the most useful in decreasing the patient's nausea.

A. Take phenazopyridine for at least 7 days. B. Phenazopyridine may change the urine color. C. Take phenazopyridine before sexual intercourse. D. Phenazopyridine may cause photosensitivity.

Correct Answer is B

Explanation

The nurse should explain to the patient that phenazopyridine is a medication that can help relieve the pain, burning, and urgency associated with UTIs. However, it does not treat the underlying infection. The nurse should also instruct the patient to take the medication as prescribed by the healthcare provider and inform them that the medication may turn their urine an orange or red color, which is a harmless and expected side eﬀect.

The nurse should also inform the patient that taking phenazopyridine before sexual intercourse is not recommended and that the medication should be taken as directed by the healthcare provider.

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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?

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Correct Answer is B

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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?