Medical Surgical 2020 RN Virtual ATI - Physiological Adaptations Quiz with solutions

A nurse is caring for a client diagnosed with diabetes. The nurse notes that the client has a mild tremor, slight diaphoresis and is fully oriented. Which of the following nursing actions should have the highest priority? Select one: a. Call the lab for a stat glucose level. b. Administer 50% Dextrose via IV push. c. Give the client 4 ounces of orange juice. d. Assess the client's blood glucose level. Correct Answer - d. Assess the client's blood glucose level. Check the patient's blood glucose. Although it is most likely that this patient is experiencing hypoglycemia, the blood glucose must be checked to confirm the problem and also to document HOW LOW the blood glucose is, which further helps determine the best treatment. Most facilities have protocols to treat hypoglycemia based on the blood glucose results. In addition, we can better evaluate how our interventions work when we compare later blood glucoses with the first blood glucose taken while the patient had symptoms. A client is admitted to the surgical unit after sustaining a compound fracture of the left femur. The client is alert and oriented with the following vital signs: T 99.4 F, P 88, R 20, B/P 94/58. The nurse notes a 4 cm. area of bright red blood on the pressure dressing on the left lower extremity. The client is receiving intravenous fluids of normal saline at 150 ml/hr. One hour after being admitted to the unit, the nurse finds the client confused and combative. Which of the following is the most likely cause of the change in the client's condition?