A client with adrenal insufficiency is admitted to the ICU with acute adrenal crisis. The client's vital signs include heart rate 138 bpm and BP 80/60. What is the nurse's first intervention?

Correct Answer: B

Rationale: In a client experiencing acute adrenal crisis, the nurse's first priority is to address the hemodynamic instability caused by the adrenal insufficiency. The correct answer, B) Administer an IV fluid bolus, is the most appropriate intervention as the client's vital signs indicate hypotension, which can be life-threatening. Administering IV fluids will help improve the client's blood pressure and perfusion to vital organs. Option A) Obtain an analgesic prescription is incorrect because pain management is not the priority in this situation. Option C) Administer PRN antipyretic is also incorrect as the client's symptoms are not suggestive of fever. Option D) Cover the client with a cooling blanket is not indicated as the client's vital signs indicate hypotension, which requires fluid resuscitation rather than cooling measures. Educationally, this question highlights the importance of prioritizing interventions based on the client's condition and vital signs in critical situations. It reinforces the concept of recognizing and managing acute adrenal crisis, a potentially life-threatening condition that requires prompt and appropriate interventions to stabilize the client's condition.

Correct Answer: A

Rationale: The correct answer is A) Use a glucometer to assess capillary glucose. This action is appropriate because the symptoms of increased hunger and thirst along with weight loss could indicate hyperglycemia, a common side effect of saquinavir and other antiretrovirals. By checking the client's capillary glucose levels, the nurse can assess for hyperglycemia and take appropriate action such as notifying the healthcare provider for medication adjustment or initiating interventions to manage high blood sugar levels. Option B) Explain to the client that an increased dose of medication is needed is incorrect because increasing the medication dose without assessing the client's glucose levels can exacerbate hyperglycemia and lead to further complications. Option C) Reassure the client that weight will improve as viral load decreases is incorrect as it does not address the immediate concern of potential hyperglycemia and weight loss. Option D) Teach the client how to measure his weight accurately is irrelevant to the client's current symptoms and does not address the potential underlying issue of hyperglycemia. In an educational context, this scenario highlights the importance of recognizing common side effects of antiretroviral medications, understanding the significance of symptoms such as increased hunger, thirst, and weight loss, and the need for timely assessment and intervention to ensure optimal client outcomes in HIV care. Regular monitoring and assessment of clients on antiretroviral therapy are essential to manage potential side effects effectively.

Correct Answer: A

Rationale: In this scenario, the most important action for the nurse to take is option A: Discuss alternative ways to support the client's birth plan. This option is the correct choice because it prioritizes client autonomy and respects the client's wishes while also ensuring their safety and well-being. By discussing alternative ways to support the client's birth plan, the nurse can explore options that align with the client's preferences while also addressing any potential concerns or risks associated with refusing induction at 42 weeks. This approach fosters a collaborative relationship between the nurse and the client, promoting trust and open communication. Option B, explaining the risks of induction after 42 weeks, while important, may come across as coercive and may not fully address the client's concerns or reasons for refusing induction. Option C shifts the responsibility to the healthcare provider without actively involving the client in the decision-making process. Option D focuses on the technical aspects of labor induction rather than the client's preferences and decision-making autonomy. Educationally, this scenario highlights the importance of client-centered care, shared decision-making, and effective communication in nursing practice. Nurses must respect and support clients' autonomous decision-making while also providing them with relevant information and guidance to make informed choices about their care.

Correct Answer: C

Rationale: In this scenario, the correct action for the nurse to implement first is to determine if the client is experiencing anxiety (Option C). This is because shortness of breath in a client with COPD and a history of emphysema can be exacerbated by anxiety, which can lead to increased respiratory distress. Auscultating lung sounds and oxygen saturation (Option B) is important but can be done after addressing the potential anxiety to provide a more accurate assessment. Notifying the healthcare provider of the client's distress (Option A) is not the first action because immediate nursing interventions are needed before involving the provider. Assessing the oxygen delivery system (Option D) is also important but should come after addressing the client's immediate distress. Educationally, this question highlights the importance of considering holistic care for clients with respiratory conditions. Nurses need to be able to prioritize interventions based on the client's presenting symptoms and potential causes. Addressing anxiety in this case can help improve the client's respiratory status and overall well-being.

Correct Answer: A

Rationale: In this scenario, the best indicator of hydration status among the options provided is option A) Urine specific gravity of 1.040. Urine specific gravity measures the concentration of solutes in the urine, with higher values indicating more concentrated urine, often seen in dehydration. A specific gravity of 1.040 is typically elevated, suggesting dehydration and fluid volume deficit in this older client. Option B) Systolic blood pressure decreasing when standing is a sign of orthostatic hypotension, which can occur in dehydration but is not as specific to hydration status as urine specific gravity. Option C) The client denying feeling thirsty is subjective and unreliable as thirst perception can be altered in older adults, making it a less reliable indicator of hydration status. Option D) Skin turgor exhibiting tenting on the forearm is a classic sign of dehydration, but it is a late sign and may not be as sensitive or specific as urine specific gravity in this case. Educationally, understanding the significance of different assessment findings in determining hydration status is crucial for nurses caring for older adults, who are at higher risk for dehydration. Monitoring urine specific gravity provides objective data to guide interventions and prevent complications related to fluid volume deficits.