Choice A is correct. The client experiencing restlessness and low blood pressure is the priority for the nurse. Following an adrenalectomy, the client is at risk for an adrenal (Addisonian) crisis from insufficient corticosteroids and aldosterone. The nurse needs to prioritize this client's situation because restlessness is an early sign of shock, and if the nurse does not follow up with the client, they run the risk of lethal cardiac dysrhythmias.

Choices B, C, and D are incorrect. An aPTT of 70 seconds is therapeutic for a client receiving a continuous heparin infusion. The goal for a client receiving an infusion of heparin is to have their aPTT 1.5x - 2.5x the control (baseline) value. The normal aPTT range is 30-40 seconds. The client receiving mechanical ventilation should be suctioned when clinically warranted. They should be assessed for the need to be suctioning every two hours, but that does not necessarily warrant suctioning at every interval. The client with a hemothorax with a chest drainage system in place does not require follow-up because the drainage is only 45 mL. Any drainage exceeding 70 mL would concern the nurse and require investigation for potential hemorrhage.

✓ During an adrenal crisis, the priority treatment is administering hydrocortisone intravenously.

✓ The client is often volume depleted, hypoglycemic, and hyponatremic and will need rapid fluid resuscitation.

✓ Dangerously high potassium levels (hyperkalemia) are also evident in an adrenal crisis and require cardiac monitoring and potassium-reducing medications such as sodium polystyrene.