Chapter 50 Questions

The nurse administers corticosteroids to a patient with acute adrenal insufficiency. The nurse determines that treatment is effective if what is observed?

A) The patient is alert and oriented. Rationale: The patient in acute adrenal insufficiency will have the following clinical manifestations: hypotension, tachycardia, dehydration, hyponatremia, hyperkalemia, hypoglycemia, fever, weakness, and confusion. Collaborative care will include administration of corticosteroids. An outcome that would indicate patient improvement would be improved level of consciousness (i.e., alert and oriented).

An IV hydrocortisone infusion is started before a patient is taken to surgery for a bilateral adrenalectomy. Which explanation, if given by the nurse, is most appropriate?

C) "This medicine is given to help your body respond to stress after removal of the adrenal glands." Rationale: Hydrocortisone is administered IV during and after a bilateral adrenalectomy to ensure adequate responses to the stress of the procedure.

Audience Response Questions: The nurse is caring for a female patient who just returned to the surgical unit following a thyroidectomy. The nurse is most concerned if which is observed?

D. The patient makes harsh, vibratory sounds when breathing. Rationale: After thyroid surgery, the patient may experience an airway obstruction related to excess swelling, hemorrhage, hematoma formation, or laryngeal stridor (harsh, vibratory sound). Emergency equipment should be at the bedside, including oxygen, suction equipment, and a tracheostomy tray.