The nurse is caring for a patient following an adrenalectomy. The highest priority in the immediate postoperative period is to
a. protect the patient's skin.
b. monitor for signs of infection.
c. balance fluids and electrolytes.
d. prevent emotional disturbances.
ANS: C
After adrenalectomy, the patient is at risk for circulatory instability caused by fluctuating hormone levels, and the focus of care is to assess and maintain fluid and electrolyte status through the use of IV fluids and corticosteroids. The other goals are also important for the patient but are not as immediately life threatening as the circulatory collapse that can occur with fluid and electrolyte disturbances.
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