NURSING 28Physiological Adaptation Quiz very correct

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. Administer 50% Dextrose via IV push. b. Call the lab for a stat glucose level. c. Assess the client's blood glucose level. d. Give the client 4 ounces of orange juice. It is very likely you will be giving orange juice, but you first MUST assess a blood glucose level. The client may be experiencing a problem other than hypoglycemia. The correct answer is: Assess the client's blood glucose level. 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? Select one: a. Hypovolemic shock related to hemorrhage from the open wound b. Fluid overload related to aggressive isotonic volume replacement c. Hypoxia related to fat embolism from the fractured bone. Although the mechanism is not really clear, it is thought that in compound long bone fractures the internal pressure in the fracture forces fat globules from the marrow into the systemic circulation, where they act as emboli. Initial symptoms within 24-48 hours post-fracture include confusion and combativeness secondary to hypoxemia. d. Infectious process related to contamination of the open wound. The correct answer is: Hypoxia related to fat embolism from the fractured bone