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Difficulty: MediumPhysiological Adaptation

A nurse is caring for a client with a history of adrenal insufficiency who was admitted for management of severe gastroenteritis. During the most recent assessment, the client appears increasingly lethargic. Vital signs show the heart rate has trended from 8282 to 114 beats/min114 \text{ beats/min}, and the blood pressure has shifted from 118/76 mm Hg118/76 \text{ mm Hg} to 102/84 mm Hg102/84 \text{ mm Hg}. Current laboratory results indicate a serum sodium of 131 mEq/L131 \text{ mEq/L} (131 mmol/L131 \text{ mmol/L}), serum potassium of 5.8 mEq/L5.8 \text{ mEq/L} (5.8 mmol/L5.8 \text{ mmol/L}), and an arterial blood gas (ABG) revealing a pH\text{pH} of 7.317.31, PaCO2\text{PaCO}_2 of 36 mm Hg36 \text{ mm Hg}, and HCO3−\text{HCO}_3^- of 18 mEq/L18 \text{ mEq/L} (18 mmol/L18 \text{ mmol/L}). Which of the following is the priority nursing intervention?

  1. Initiate a rapid intravenous infusion of 0.9% sodium chloride.Answer
  2. B
    Administer intravenous sodium bicarbonate to correct the acidosis.
  3. C
    Provide oral rehydration fluids and reassess vital signs in one hour.
  4. D
    Administer sodium polystyrene sulfonate to treat the hyperkalemia.

Answer

The correct priority intervention is to initiate a rapid intravenous infusion of 0.9% sodium chloride to treat impending hypovolemic shock.
This client is demonstrating early signs of hypovolemic shock (tachycardia and a notably narrowed pulse pressure) exacerbated by underlying adrenal insufficiency and gastroenteritis. In any shock state, the absolute priority according to the ABCs (Airway, Breathing, Circulation) framework is to restore intravascular volume. A rapid infusion of an isotonic crystalloid, such as 0.9%0.9\% sodium chloride, is the most immediate life-saving intervention to support blood pressure, enhance tissue perfusion, and prevent total cardiovascular collapse.

Step-by-Step Solution

1
Analyze the clinical presentation and vital sign trends.
The client has a history of adrenal insufficiency, ongoing fluid loss from gastroenteritis, new-onset lethargy, tachycardia (114 beats/min114 \text{ beats/min}), and a narrowing pulse pressure (102/84 mm Hg102/84 \text{ mm Hg}, which is a pulse pressure of 18 mm Hg18 \text{ mm Hg}).
These findings represent the early, compensatory phase of hypovolemic shock progressing toward an acute adrenal (Addisonian) crisis.
2
Interpret the laboratory and arterial blood gas data.
Labs reveal hyponatremia, hyperkalemia, and uncompensated metabolic acidosis.
The electrolyte imbalances are classic for aldosterone deficiency, while the metabolic acidosis is primarily a result of tissue hypoperfusion causing lactic acid buildup.
3
Determine the priority action using the Airway, Breathing, Circulation (ABC) framework.
The most immediate life-threatening issue is a profound circulation deficit requiring rapid volume replacement.
Isotonic crystalloids (like 0.9%0.9\% sodium chloride) are the universal first-line treatment to restore intravascular volume, support blood pressure, and reverse tissue hypoperfusion.

Key Concept

Early recognition and treatment of hypovolemic shock in acute adrenal insufficiency, prioritizing circulation and intravascular volume replacement.
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Topics

Physiological Adaptation

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