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A nurse is caring for a client with suspected pheochromocytoma. The nurse recognizes that which of the following is the priority action?

A.

Obtain hourly glucose levels

B.

Prepare client for a CT scan

C.

Request order for serum calcium levels

D.

Monitor Blood Pressure

Answer and Explanation

The Correct Answer is D

A. Monitoring glucose levels may be necessary, as pheochromocytoma can cause hyperglycemia, but it is not the immediate priority.  

 

B. A CT scan may be part of the diagnostic process to locate the adrenal tumor, but the priority is to control blood pressure first due to the risk of severe hypertensive crisis.  

 

C. Serum calcium levels are not directly related to pheochromocytoma and are not a priority action.  

 

D. Monitoring blood pressure is critical, as pheochromocytoma causes episodes of severe hypertension, which can lead to life-threatening complications.


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Correct Answer is D

Explanation

A. Monitoring glucose levels may be necessary, as pheochromocytoma can cause hyperglycemia, but it is not the immediate priority.

B. A CT scan may be part of the diagnostic process to locate the adrenal tumor, but the priority is to control blood pressure first due to the risk of severe hypertensive crisis.

C. Serum calcium levels are not directly related to pheochromocytoma and are not a priority action.

D. Monitoring blood pressure is critical, as pheochromocytoma causes episodes of severe hypertension, which can lead to life-threatening complications.

Correct Answer is A

Explanation

A. Assessing respiratory status and airway patency is the highest priority in this situation due to the risk of respiratory compromise from cervical spinal cord injuries, which can affect the diaphragm and other respiratory muscles.

B. While assessing extremity strength and sensation is important, it comes after ensuring the client’s airway and breathing are stable.

C. Pain management is essential, but addressing immediate life-threatening conditions takes precedence over pain assessment.

D. Assessing the client's level of consciousness is crucial for overall evaluation but does not take priority over ensuring adequate respiratory function in the context of a cervical spinal cord injury.

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