A client with a history of primary adrenal insufficiency presents with vomiting, hypotension 84/52, blood glucose 58, sodium 128, potassium 5.8 after stopping prednisone for 3 days because of nausea. Which intervention is the most immediate priority?
1Administer IV hydrocortisone 100 mg as the immediate priority✓ Correct answer
2Replace potassium aggressively because of dehydration
3Wait for cortisol level result before steroid administration
4Initiate IV insulin drip for blood glucose 58 mg/dL
Explanation
Adrenal crisis is a life-threatening emergency. IV hydrocortisone 100 mg bolus is given IMMEDIATELY without waiting for confirmatory testing. Volume resuscitation with isotonic saline plus dextrose for hypoglycemia follows. Insulin would WORSEN hypoglycemia (glucose 58). Potassium is HIGH (5.8) so potassium replacement is contraindicated; volume expansion and steroids correct it. Cortisol can be drawn but treatment must NEVER be delayed.
Sick day rule: triple oral steroid dose with febrile illness; switch to IV stress-dose for vomiting or unable to keep oral. Patient must wear medical alert.
Lethargic but arousable. HR 122, RR 24, temp 37.8 C. No history of cardiac disease.
adrenal crisis — Acute decompensation of adrenal insufficiency with hypotension and hypoglycemia.
stress-dose steroid — Increased glucocorticoid for illness, surgery, or trauma in adrenal insufficiency.
primary adrenal insufficiency — Adrenal cortex failure (Addison disease); both cortisol and aldosterone deficient.