A patient with a history of adrenal insufficiency has been admitted to the intensive care unit due to an acute adrenal crisis.
The patient is experiencing nausea and joint pain.
The patient’s vital signs are as follows: temperature of 102 F (38.9° C), heart rate of 138 beats/minute, and blood pressure of 80/60 mm Hg. What is the first intervention the nurse should implement?
Obtain an analgesic prescription
Infuse an intravenous fluid bolus
Administer PRN oral antipyretic
Cover the patient with a cooling blanket
The Correct Answer is B
Choice A rationale
While obtaining an analgesic prescription might help to alleviate the patient’s joint pain, it is not the first intervention that should be implemented in an acute adrenal crisis. The patient’s low blood pressure and high heart rate are immediate life-threatening conditions that need to be addressed first.
Choice B rationale
Infusing an intravenous fluid bolus is the first intervention that should be implemented in an acute adrenal crisis. This can help to increase the patient’s blood pressure, which is dangerously low.
Choice C rationale
Administering a PRN oral antipyretic could help to reduce the patient’s fever, but it is not the first intervention that should be implemented in an acute adrenal crisis. The patient’s low blood pressure and high heart rate are immediate life-threatening conditions that need to be addressed first.
Choice D rationale
Covering the patient with a cooling blanket could help to reduce the patient’s fever, but it is not the first intervention that should be implemented in an acute adrenal crisis. The patient’s low blood pressure and high heart rate are immediate life-threatening conditions that need to be addressed first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Heparin is an anticoagulant medication that prevents the formation of blood clots. One of the most common and serious side effects of heparin therapy is bleeding. Therefore, it is crucial for the nurse to observe for signs of bleeding, such as bruising, petechiae, hematomas, black tarry stools, hematuria, and changes in mental status. Regular laboratory monitoring of the client’s coagulation status, specifically the activated partial thromboplastin time (aPTT), is also necessary to ensure therapeutic levels of heparin without causing excessive bleeding.
Choice B rationale
While mobilization can help prevent the formation of new clots, it is not the most important intervention for a client who is already on a heparin protocol for DVT. Mobilization can potentially dislodge the existing clot, leading to a life-threatening pulmonary embolism.
Choice C rationale
Although it is important to monitor vital signs in all clients, assessing blood pressure and heart rate every 4 hours is not the most important intervention for a client on a heparin protocol.
Changes in blood pressure and heart rate are not specific to heparin therapy and do not provide direct information about the effectiveness or side effects of the medication.
Choice D rationale
Measuring each calf’s girth can help evaluate the progression of edema in the affected leg, but it is not the most important intervention for a client on a heparin protocol. While it can provide information about the local effects of the DVT, it does not address the systemic anticoagulation effects of heparin therapy.
Correct Answer is C
Explanation
Choice A rationale
While the sensitivity of genetic markers can influence the choice of treatment, it is not the primary pathophysiological process involved in BRCA1 and BRCA2 genetic testing. The main purpose of these tests is to identify genetic mutations that increase the risk of developing certain types of cancer.
Choice B rationale
BRCA1 and BRCA2 do play a role in protecting mature, functioning breast and ovarian cells. However, this is not the primary reason for conducting BRCA1 and BRCA2 genetic testing. The main purpose of these tests is to identify mutations that increase cancer risk.
Choice C rationale
This is the correct answer. Mutations in BRCA1 or BRCA2 can significantly increase a person’s risk for developing breast and ovarian cancer. Therefore, identifying these mutations through genetic testing can help determine a person’s cancer risk.
Choice D rationale
While inherited mutations in BRCA1 and BRCA2 can influence the prognosis of breast cancer, the primary purpose of BRCA1 and BRCA2 genetic testing is to identify mutations that increase cancer risk, not to determine prognosis.
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