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
Ceasing the use of the nasal cannula would interrupt the client’s oxygen therapy, which could potentially worsen their condition. Therefore, this is not the best course of action.
Choice B rationale
Reducing the flow rate to 1 L/minute may not be appropriate as the client’s oxygen needs may not be met at a lower flow rate. The redness under the chin is likely due to the friction from the cannula tubing, not the flow rate of the oxygen.
Choice C rationale
Applying lubricant to the cannula tubing may not be effective in preventing skin breakdown and could potentially cause additional discomfort or complications for the client.
Choice D rationale
Attaching padding around the cannula tubing can help reduce the friction between the tubing and the skin, which can help prevent skin breakdown. This is the most appropriate action to take in this situation.
Correct Answer is ["A","C","D","E"]
Explanation
Choice A rationale
A sudden change in behavior, especially confusion and agitation, in an elderly patient could be a sign of a urinary tract infection (UTI). Pain during urination is a common symptom of UTIs.
Therefore, it is crucial to inquire if the patient is experiencing any pain during urination.
Choice B rationale
While a high-protein diet can be beneficial for some patients, there is no direct link between increased protein intake and the alleviation of confusion or agitation in elderly patients.
Therefore, this option is not a necessary immediate action for the nurse to take.
Choice C rationale
Reviewing the patient’s current food and medication allergies is important. Certain medications or foods might cause adverse reactions, including confusion and agitation. Therefore, it is crucial to review the patient’s allergies to rule out any potential allergens as the cause of the sudden change in behavior.
Choice D rationale
A recent fall could potentially lead to a head injury, which might cause confusion and agitation. Therefore, it is important to determine if the patient has recently experienced a fall.
Choice E rationale
Providing instructions on how to take the patient’s temperature is important. Fever could be a sign of an infection or other medical condition that might cause confusion and agitation.
Therefore, knowing how to accurately measure the patient’s temperature can help monitor the patient’s condition.
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