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 D
Explanation
Choice A rationale
Administering the medication at 1000, 1600, 2200, and 0400 would not be the best schedule because it does not evenly distribute the doses throughout the day. This could lead to periods of subtherapeutic medication levels and periods of potential toxicity.
Choice B rationale
Administering the medication with meals and a bedtime snack is not the best schedule for this medication. While some medications need to be administered with food, there is no indication
that this medication needs to be. Furthermore, this schedule could lead to uneven distribution of the medication throughout the day.
Choice C rationale
Giving the medication in equally divided doses during waking hours is not the best schedule because it does not take into account the half-life of the medication or the patient’s sleep schedule. This could lead to subtherapeutic levels of the medication during the night.
Choice D rationale
Administering the medication at 0800, 1200, 1600, and 2000 is the best schedule for this medication. It evenly distributes the doses throughout the day, which can help maintain a therapeutic level of the medication and reduce the risk of toxicity.
Correct Answer is C
Explanation
Choice A rationale
Comparing muscle strength bilaterally is not the most important intervention in this situation. While muscle weakness can be a symptom of hyperkalemia, it is not the most immediate concern. Hyperkalemia can lead to life-threatening cardiac dysrhythmias, which is a more immediate threat to the patient’s life.
Choice B rationale
Observing the color and amount of urine can provide information about the patient’s renal function, which is important in the regulation of potassium. However, this is not the most immediate concern when a patient’s serum potassium level is dangerously high.
Choice C rationale
Determining the apical pulse rate and rhythm is the most important intervention. Hyperkalemia can cause cardiac dysrhythmias, so the nurse should immediately assess the patient’s heart rate and rhythm. The nurse should also place the patient on a cardiac monitor, if not already done, and notify the healthcare provider immediately.
Choice D rationale
Assessing the strength of deep tendon reflexes can provide information about neuromuscular function, which can be affected by hyperkalemia. However, this is not the most immediate concern. The nurse’s priority is to assess and monitor for life-threatening cardiac dysrhythmias.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.