# A 60-year-old client on chronic prednisone 10 mg daily for severe asthma calls the clinic with influenza, fever 39°C, vomiting twice today, and inability to keep oral fluids down. Which response by the nurse is most appropriate?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=375101&lang=en  
> language: en  
> subject: Medical Emergencies  
> category: PA

## Question

A 60-year-old client on chronic prednisone 10 mg daily for severe asthma calls the clinic with influenza, fever 39°C, vomiting twice today, and inability to keep oral fluids down. Which response by the nurse is most appropriate?

## Option

1. You can manage this at home with rest and small ice chips; call back if you are unable to tolerate any liquids after 24 hours.
2. Take 30 mg prednisone (triple your daily dose) orally and rest to prevent adrenal insufficiency; call if vomiting persists.
3. Come in for evaluation; you may need a stress dose of IV or IM hydrocortisone, IV fluids, and antiemetics to prevent adrenal crisis. **✔ Correct answer**
4. Because you are vomiting, you should skip today's prednisone; the steroid may increase gastric irritation and delay your recovery from this illness.

**Correct answer: 3**

## Explanation

Patients on long-term corticosteroids cannot mount a normal cortisol response to physiologic stress (illness, surgery, trauma) because of HPA-axis suppression. The standard sick day rule is to double or triple the daily oral dose during minor illness, but if the patient cannot keep oral medication down because of vomiting or diarrhea, parenteral hydrocortisone (50 to 100 mg IV or IM) is required to prevent adrenal crisis. Skipping the dose, waiting 24 hours, or telling the patient to triple at home while vomiting all risk progression to crisis: hypotension, hypovolemia, hypoglycemia, hyperkalemia, hyponatremia, and shock. The nurse instructs the patient to come in for parenteral steroid, IV fluid resuscitation, antiemetics, and evaluation of the underlying illness. Patients should also know to seek care for surgery, severe trauma, or any persistent inability to take oral medication.

## In-depth explanation

Vomiting plus chronic steroid plus acute illness is the textbook indication for parenteral stress dosing. Choosing parenteral hydrocortisone over PO is the priority pharmacology decision.

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