A client on corticosteroid therapy is returning from surgery after a hip replacement. In the past two hours his blood pressure has decreased from 126/76 to 104/60, he is restless and complains of a headache. The nurse should:
a. medicate the client for pain as prescribed.
b. notify the health care provider immediately.
c. Increase his current intravenous fluid rate from 125 mL/hr to 150 mL/hr.
d. Monitor his blood pressure and position him for comfort.
ANS: B
Feedback
A Incorrect: These are manifestations of adrenal crisis requiring immediate medical care.
B Correct: These are manifestations of adrenal crisis requiring immediate medical care.
C Incorrect: Without a protocol or prescription, this is not within the nurse's scope of practice.
D Incorrect: These are manifestations of adrenal crisis requiring immediate medical care.
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