# A 50-year-old client who has taken prednisone 30 mg daily for 14 months for inflammatory bowel disease ran out of medication 4 days ago. The client now presents with severe fatigue, vomiting, abdominal pain, BP 80/48, HR 124, glucose 58 mg/dL, sodium 128 mEq/L, potassium 5.8 mEq/L. Which set of priority interventions should the nurse prepare to implement?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=375102&lang=en  
> language: en  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PA

## Question

A 50-year-old client who has taken prednisone 30 mg daily for 14 months for inflammatory bowel disease ran out of medication 4 days ago. The client now presents with severe fatigue, vomiting, abdominal pain, BP 80/48, HR 124, glucose 58 mg/dL, sodium 128 mEq/L, potassium 5.8 mEq/L. Which set of priority interventions should the nurse prepare to implement?

## Option

1. Establish two large-bore IVs; administer hydrocortisone 100 mg IV push, normal saline 1 L bolus with 5% dextrose, and continuous cardiac monitoring while preparing for ICU transfer. **✔ Correct answer**
2. Administer ondansetron 4 mg IV for nausea, restart oral prednisone 30 mg daily after vomiting resolves, and schedule a follow-up with the primary care provider within one week.
3. Place the client NPO, administer 0.9% sodium chloride at 75 mL/hour, and arrange an urgent CT scan of the abdomen and pelvis with contrast to evaluate for obstruction or perforation.
4. Administer 10 units of regular insulin IV push with 50 mL of 50% dextrose, then reassess serum potassium and blood glucose every 30 minutes until levels normalize.

**Correct answer: 1**

## Explanation

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.

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