A 46-year-old female patient presents to the emergency department with acute adrenal insufficiency and the following vital signs: P 118 beats/min, R 18 breaths/min, BP 83/44 mm Hg. pulse oximetry 98%. and T 98.8 F oral.
Which nursing intervention is the highest priority for this patient?
Administering furosemide (Lasix)
Replacing potassium losses
Providing isotonic fluids
Restricting sodium.
The Correct Answer is C
The patient's vital signs suggest that she is experiencing hypotension, tachycardia, and possibly dehydration due to acute adrenal insufficiency. The highest priority nursing intervention for this patient is to provide isotonic fluids to restore intravascular volume and blood pressure. This will also help to correct any electrolyte imbalances that may be present. Administering furosemide (Lasix) or replacing potassium losses may be necessary interventions, but they are not the highest priority at this time. Restricting sodium would be contraindicated in this situation as the patient is hypotensive and needs fluids to increase intravascular volume.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Desmopressin acetate (DDAVP) is a synthetic hormone used to treat diabetes insipidus, which is a condition that causes excessive urination and thirst due to a lack of antidiuretic hormone (ADH) production in the body. By mimicking the effects of ADH, Desmopressin acetate (DDAVP) helps to reduce the amount of urine produced by the body and increase water reabsorption, which helps to alleviate symptoms of diabetes insipidus.
Therefore, the nurse should monitor the patient's urinary output and ensure that it decreases in response to the medication. It is important to note that Desmopressin acetate (DDAVP) can also cause hyponatremia (low sodium levels in the blood), so sodium levels should also be monitored during treatment.
Correct Answer is A
Explanation
The nurse should anticipate that the patient will need to collect a stool specimen. Diarrhea can be caused by various factors such as infections, inflammatory bowel disease, food intolerance, and medication side effects. Collecting a stool specimen can help identify the underlying cause of the diarrhea and guide appropriate treatment. Blood cultures, colonoscopy but barium enema may be necessary in certain cases but are not typically the first step in the diagnostic process for diarrhea.
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