A client with a history of adrenal insufficiency is admitted to the intensive care unit with an acute adrenal crisis. The client is complaining of nausea and joint pain.
Vital signs are: temperature 102° F (38.9° C), heart rate 138 beats/minute, blood pressure 80/60 mm Hg. Which intervention should the nurse implement first?
Obtain an analgesic prescription.
Infuse an intravenous fluid bolus.
Administer PRN oral antipyretic.
Cover client with a cooling blanket.
The Correct Answer is B
Choice A rationale
While obtaining an analgesic prescription might help to alleviate the client’s joint pain, it is not the first intervention that should be implemented. The client’s vital signs indicate that they are in a state of shock, which is a medical emergency.
Choice B rationale
Infusing an intravenous fluid bolus is often the first step in treating shock. The client’s low blood pressure and high heart rate suggest that they may be experiencing hypovolemic shock, which can be caused by a severe fluid loss. Administering fluids can help to increase blood volume and improve blood pressure.
Choice C rationale
Administering a PRN oral antipyretic would not address the client’s immediate need. The client’s high temperature is a concern, but the low blood pressure and high heart rate are more immediate concerns.
Choice D rationale
Covering the client with a cooling blanket would address the client’s high temperature, but it would not address the more immediate concerns of low blood pressure and high heart rate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
Choice A rationale
Administering IV fluids is a potential nursing intervention for several body systems. For example, the circulatory system may require IV fluids to maintain blood volume and pressure. The renal system may need IV fluids to ensure adequate urine output. The digestive system might need IV fluids to compensate for losses from vomiting or diarrhea.
Choice B rationale
Assessing a rash is a potential nursing intervention for the integumentary system. Rashes can be a sign of many different conditions, including allergic reactions, infections, autoimmune diseases, and more. By assessing the rash, the nurse can gather information to help determine its cause and appropriate treatment.
Choice C rationale
Administering an antihistamine is a potential nursing intervention for the immune system. Antihistamines are often used to treat allergic reactions, which involve the immune system.
They can also be used to treat symptoms of the common cold, which is caused by a viral infection.
Choice D rationale
Administering a steroid is a potential nursing intervention for several body systems. Steroids can be used to reduce inflammation, which can benefit the musculoskeletal, integumentary, respiratory, and other systems. They can also be used to treat certain endocrine disorders.
Correct Answer is C
Explanation
Choice A rationale
Moon facies, characterized by a round face, is a side effect of long-term use of prednisone. However, it is not the most important symptom for the client to report to the healthcare provider in this context.
Choice B rationale
Abdominal striae, or stretch marks on the abdomen, can also be a side effect of long-term use of prednisone. While it may be a concern for some patients due to cosmetic reasons, it is not the most critical symptom to report in this case.
Choice C rationale
Gastric irritation is a common side effect of prednisone and can lead to more serious complications such as gastric ulcers if not addressed promptly. Therefore, it is the most important symptom for the client to report to the healthcare provider.
Choice D rationale
Rapid weight gain can be a side effect of prednisone use. While it is important to monitor weight while on this medication, it is not the most critical symptom to report in comparison to gastric irritation.
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