A client with Addison's disease becomes weak, confused, and dehydrated following the onset of an acute viral infection. The client's laboratory values include: sodium 129 mEq/L (129 mmol/L), glucose 54 mg/dl (2.97 mmol/L) and potassium 5.3 mEq/L (5.3 mmol/L).
When reporting the findings to the healthcare provider, the nurse anticipates a prescription for which intravenous medication?
Reference Ranges
- Sodium [Reference Range: Adult 136 to 145 mEq/L (136 to 145 mmol/L)
- Glucose (Reference Range: 0 to 50 years: 74 to 106 mg/dl. (4.1 to 5.9 mmol/L))
- Potassium [Reference Range: 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)
Broad spectrum antibiotic.
Regular insulin.
Hydrocortisone.
Potassium chloride.
The Correct Answer is C
The client with Addison's disease is experiencing weakness, confusion, and dehydration, which can be indicative of an adrenal crisis. The low sodium level (129 mEq/L) and low glucose level (54 mg/dl) further support this suspicion. An acute viral infection can trigger an adrenal crisis in individuals with Addison's disease.
Intravenous hydrocortisone, a glucocorticoid, is the treatment of choice for managing an adrenal crisis. It helps to replenish cortisol levels and stabilize the client's condition.
Hydrocortisone helps in restoring the body's stress response and regulating electrolyte and glucose levels.
A broad-spectrum antibiotic may be necessary if there is evidence of a bacterial infection, but it does not directly address the symptoms associated with Addison's disease.
Regular insulin is used for managing high blood glucose levels in conditions such as diabetes, but in this case, the client has low glucose levels, so insulin is not the appropriate intervention.
Potassium chloride is a medication used to treat low potassium levels (hypokalemia), but the client's potassium level is within the reference range (5.3 mEq/L). Therefore, potassium chloride is not indicated in this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) This can be done if initial non-pharmacological interventions do not relieve symptoms, but it is not the first step.
B) Monitoring blood pressure is important, but it is secondary to removing the stimulus causing the dysreflexia.
C) Incorrect- While education is important for long-term management, the client is currently experiencing symptoms that need immediate attention. The priority is to assess and address the current symptoms.
D) The client is likely experiencing autonomic dysreflexia, characterized by a sudden and severe increase in blood pressure, flushing, headache, and other symptoms triggered by a noxious stimulus below the level of injury. The first step in managing autonomic dysreflexia is to identify and eliminate the triggering stimulus. For clients with a Foley catheter, a common cause of autonomic dysreflexia is bladder distention due to a kinked or obstructed catheter. Relieving any kinks or obstructions in the Foley tubing can immediately alleviate the symptoms.
Correct Answer is B
Explanation
The client's serum potassium level is elevated at 6.0 mEq/L (6.0 mmol/L), which is above the normal reference range of 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L).
Hyperkalemia can have significant cardiac implications, including the potential for life-threatening dysrhythmias. Therefore, close monitoring of the serum potassium level is crucial to assess the effectiveness of interventions and ensure that potassium levels are within a safe range.
While monitoring glucose levels before and after meals is important for clients receiving insulin therapy, in this scenario, the primary concern is the elevated potassium level.
The nurse should prioritize frequent assessment of the serum potassium level to guide appropriate management and prevent complications associated with hyperkalemia.
Monitoring and documenting strict intake and output are important for assessing fluid balance and renal function, but in this case, the elevated potassium level takes precedence as it poses a more immediate risk to the client's well-being.
Obtaining a 12-lead electrocardiogram (ECG) daily may be indicated in some cases of hyperkalemia, as certain ECG changes can be associated with elevated potassium levels. However, the more critical aspect is monitoring the potassium level itself, as ECG changes can occur rapidly and may not always be detectable on a daily basis.
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