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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Since the patient's pre meal blood sugar is 311 mg/dL, according to the sliding scale, the patient requires 8 units of Humalog insulin. Therefore, the nurse should administer 8 units of Humalog insulin before the patient's meal. It is important to note that if the patient's blood glucose level is greater than 400 mg/dL, the nurse should call the MD instead of administering insulin. Keeping the patient NPO (nothing by mouth) is not necessary in this situation, as the patient is awake, alert, and able to swallow, and will require their meal for adequate nutrition. However, it is important to monitor the patient's blood glucose level after administering insulin and adjust the dosage if necessary.
Correct Answer is A
Explanation
Prochlorperazine is an antiemetic medication that is commonly used to treat nausea and vomiting caused by various conditions, including chemotherapy, radiation therapy, and surgery. Giving the medication before the dressing changes, can prevent or minimize the onset of nausea and vomiting, which can be triggered by the pain and anxiety associated with the procedure.
Option B, keeping the patient NPO (nothing by mouth) for 2 hours before dressing changes, may be helpful in reducing the risk of aspiration if the patient needs sedation or general anesthesia for the procedure. However, it is not directly related to reducing the patient's nausea.
Option C, avoiding performing dressing changes close to the patient's mealtimes, may help reduce the risk of nausea caused by an overly full stomach, but it is not directly related to reducing the patient's nausea during the procedure.
Option D, administering prescribed morphine sulfate before dressing changes, may help reduce the patient's pain during the procedure, but it may also increase the risk of nausea and vomiting as a side effect. Therefore, this option may not be the most useful in decreasing the patient's nausea.
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