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 D
Explanation
Choice A rationale
Offering the client oral fluids is important for hydration, but it is not directly related to the care of an indwelling urinary catheter. The UAP can offer fluids to the client, but this action is not specifically tied to the turning of the client or the care of the urinary catheter.
Choice B rationale
Feeding the client a snack is a task that the UAP may perform, but it is not directly related to the care of an indwelling urinary catheter. The UAP can provide a snack to the client, but this action is not specifically tied to the turning of the client or the care of the urinary catheter.
Choice C rationale
Assessing breath sounds is within the scope of practice for a nurse, not a UAP. While it’s important to monitor a client’s respiratory status, this action is not directly related to the care of an indwelling urinary catheter.
Choice D rationale
Emptying the urinary drainage bag is an appropriate action for the UAP to take each time the client is turned. This action helps to prevent infection, maintain accurate intake and output records, and ensure the comfort and dignity of the client.
Correct Answer is D
Explanation
Choice A rationale
While abdominal cramping can be a symptom of gastritis, it is not typically a sign of a serious complication that would require immediate medical attention.
Choice B rationale
Bruising of the skin is not typically associated with gastritis. If the client notices unexplained bruising, they should report it, but it is not the most critical symptom to watch for.
Choice C rationale
A low-grade fever can be a symptom of gastritis, but it is not typically a sign of a serious complication. The client should monitor their temperature, but it is not the most critical symptom to watch for.
Choice D rationale
Bloody emesis can be a sign of a serious complication of gastritis, such as a bleeding ulcer. If the client notices bloody or coffee-ground emesis, they should seek medical attention immediately.
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