NURSING 123 A nurse is caring for a client diagnosed with diabetes. (Fully Answered)

NURSING 123 A nurse is caring for a client diagnosed with diabetes. (Fully Answered)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. 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. d. Give the client 4 ounces of orange juice. Feedback 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. Fluid overload related to aggressive isotonic volume replacement b. 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. c. Hypovolemic shock related to hemorrhage from the open wound d. Infectious process related to contamination of the open wound. Feedback The correct answer is: Hypoxia related to fat embolism from the fractured bone. A nurse is caring for a client on the telemetry unit who is two days post coronary artery bypass grafting (CABG). The nurse recognizes a cardiac rhythm change from normal sinus rhythm to atrial fibrillation. Which of the following should be completed first? Select one: a. Prepare the client for cardioversion. b. Notify the health care provider. ' c. Assess the client’s blood pressure. Atrial fibrillation frequently occurs after CABG. In A-Fib the atrial kick is lost and cardiac output (C.O.) is decreased by 30%. Clients react differently to A-Fib and the decreased C.O. Some clients become hypotensive and develop shock-like symptoms: changes in LOC; cool, clammy skin; dyspnea; and chest pain. While other clients are normotensive despite the decrease in C.O., they are asymptomatic or considered stable. Treatment for A-Fib depends on the status of the client. The first action the nurse should take with a client who has converted from NSR to A-Fib is to assess the clients BP.*************continues