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 ["C","D"]
Explanation
Option A is not the best advice because drinking lots of water alone may not be enough to relieve constipation, especially if there is an obstruction.
Option B is also not accurate because not all intestinal obstructions require surgery, and the treatment approach will depend on the cause and severity of the obstruction.
Option C is accurate because a nasogastric tube can help relieve any distention caused by the obstruction by removing any gas or fluids that may have accumulated in the stomach and small intestine.
Option D is also accurate because an abdominal CT is one of the diagnostic tests that can help confirm the presence of intestinal obstruction and provide information about the location and cause of the obstruction.
Correct Answer is ["A","D"]
Explanation
The serum laboratory test results that support the probable diagnosis of hyperthyroidism in a 40- year-old female client with a family history of thyroid problems and presenting with symptoms of unintentional weight loss, irritability, and chest discomfort are increased T4 (thyroxine) and T3 (triiodothyronine) levels, as hyperthyroidism is characterized by excess production of thyroid hormones. Options b, c, e, f, and g are not typically associated with hyperthyroidism.
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