A client with a history of adrenal insufficiency is admitted to the intensive care unit with an acute adrenal crisis. The client is complaining of nausea and joint pain.
Which intervention should the nurse implement first?
Obtain an analgesic prescription.
Cover client with a cooling blanket.
Infuse an intravenous fluid bolus.
Administer PRN oral antipyretic.
The Correct Answer is C
A. Obtaining an analgesic prescription addresses pain but is not the most urgent need in the context of an acute adrenal crisis with hypotension.
B. Covering the client with a cooling blanket addresses fever but is not the priority intervention compared to managing the client’s critical low blood pressure and shock.
C. Infusing an intravenous fluid bolus is the most critical intervention for managing hypotension in an acute adrenal crisis. Fluid resuscitation is essential to stabilize blood pressure and address the crisis.
D. Administering a PRN oral antipyretic would help manage fever but does not address the more immediate issue of hypotension and shock.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Increase in respiratory rate: An increase in respiratory rate may indicate respiratory distress or worsening condition, not necessarily the effectiveness of CPT.
B. Absence of coarse crackles: Coarse crackles are indicative of secretions in the airways. Their absence after CPT indicates that the therapy has helped mobilize and clear the secretions.
C. Absence of fine crackles: Fine crackles might be present due to other issues, so their absence does not directly indicate the effectiveness of CPT in mobilizing secretions.
D. Increase in breath sounds: An increase in breath sounds alone does not necessarily indicate the effectiveness of CPT in mobilizing secretions.
Correct Answer is D
Explanation
A. Administer naloxone per PRN protocol: Naloxone is used for opioid overdoses, not for benzodiazepine withdrawal. Therefore, this action is not appropriate for managing symptoms of alprazolam withdrawal.
B. Obtain a serum drug screen: While a drug screen can provide information about substance use, the immediate priority is managing the client’s withdrawal symptoms, including the risk of seizures.
C. Instruct the family about withdrawal symptoms: While educating the family is important, it is not the immediate priority. Addressing acute symptoms and risks takes precedence in this situation.
D. Initiate seizure precautions: Severe agitation and tremors can escalate to seizures during benzodiazepine withdrawal. Initiating seizure precautions ensures the client's safety and addresses the immediate risks associated with withdrawal.
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