The presentation is acute adrenal (Addisonian) crisis precipitated by abrupt discontinuation of long-term high-dose prednisone in a patient with HPA-axis suppression. Diagnostic clues: hypotension refractory to fluids, hypoglycemia, hyponatremia, hyperkalemia, hypovolemia, and tachycardia in a patient with steroid history and a missed dose. Priority interventions in this exact order: (1) two large-bore IVs and immediate IV hydrocortisone 100 mg bolus (then 50 to 100 mg every 6 hours or 200 mg over 24 hours by infusion), (2) rapid normal saline 1 L IV bolus repeated as needed, with 5 percent dextrose to correct hypoglycemia, (3) continuous cardiac monitor and 12-lead ECG because hyperkalemia plus hypovolemia plus hypotension raise arrhythmia risk, (4) prepare for ICU admission, (5) identify and treat the precipitant (often missed dose, infection, surgery, or trauma). Restarting oral prednisone alone is inadequate because of vomiting and shock physiology. Insulin lowers potassium but the priority is steroid replacement which itself corrects sodium, glucose, potassium, and hemodynamics. Holding all medications and CT delay treatment.
In-depth explanation
Adrenal crisis is treated by IV hydrocortisone, IV NS with dextrose, and ICU monitoring all at once — not sequentially. The classic NCLEX trap is to address hyperkalemia or hypoglycemia in isolation; the steroid replacement addresses the physiologic root cause.
For study reference only. Always follow current clinical guidelines and your institution’s protocols.