A nurse is caring for a client who is 12 hr postoperative and has a chest tube to a disposable water-seal drainage system with suction. The nurse should intervene for which of the following observations?

A. After administering a carbohydrate source (e.g., 6 oz of orange juice), the nurse should reassess the patient's blood glucose level. If the glucose is still below the target range (typically above 70 mg/dL), the next step is to give an additional 15 grams of carbohydrate to raise the blood sugar. This is a standard approach for mild to moderate hypoglycemia.
B. Giving 25 to 50 ml of 50% glucose IV is typically reserved for patients who are severely hypoglycemic and unable to swallow or are unresponsive. This method is appropriate when the patient cannot take oral glucose, but the client in this scenario is still conscious.
C. Administering 1 mg IM glucagon is used when a patient is unable to ingest glucose orally and is unresponsive or vomiting. It stimulates the liver to release stored glucose, but this is not necessary in a conscious patient who can swallow.
D. Administering a 5% to 10% dextrose infusion is typically used in more severe cases of hypoglycemia, especially when IV access is established, and the patient is unable to take oral glucose. This would not be necessary for a patient who can safely swallow.

A. A peak flow of more than 40% would indicate that the patient's asthma is not in an acute exacerbation. This patient's symptoms, such as confusion and inability to speak, suggest a severe asthma attack, and the peak flow would likely be much lower.
B. Bradycardia is not typically associated with severe asthma exacerbations. Tachycardia is more commonly observed as the body attempts to compensate for hypoxia.
C. Loud and prominent wheezing is usually seen in less severe cases of asthma. In this case, the inability to speak and confusion suggest severe respiratory distress, where wheezing might be diminished or absent due to poor air movement.
D. Deteriorating arterial blood gas (ABG) results, with low oxygen levels (hypoxemia) and elevated carbon dioxide levels (hypercapnia), would be expected in a patient with severe asthma exacerbation. These signs indicate respiratory failure and the need for urgent intervention.