A client who suffered an electrical injury with the entrance site on the left hand and the exit site on the left foot is admitted to the burn unit. Which intervention is most important for the nurse to include in this client’s plan of care?

Choice A reason: Increased oral fluid intake is a general recommendation for clients with an infection to prevent dehydration and help thin respiratory secretions. While staying hydrated is important, it is not a specific change in blood glucose management for a client with diabetes and an upper respiratory infection.

Choice B reason: Restriction of caloric intake is not appropriate advice for a client with diabetes and an infection. During illness, the body’s metabolic needs increase, and caloric intake should be adjusted to meet these needs. Restricting calories can lead to inadequate nutrition and further complications.

Choice C reason: Higher doses of insulin are often needed for clients with diabetes who are experiencing an infection. Infections can cause increased stress on the body, leading to elevated blood glucose levels. The body’s inflammatory response and the release of stress hormones can result in insulin resistance and higher blood sugar levels. Therefore, it is common for healthcare providers to adjust insulin doses upward to manage these changes and maintain glycemic control during periods of illness.

Choice D reason: Fewer fingerstick glucose checks are not recommended. In fact, during illness, it is crucial for clients with diabetes to monitor their blood glucose levels more frequently. Close monitoring helps to detect hyperglycemia or hypoglycemia and allows for timely adjustments in insulin or other diabetes medications. Frequent glucose checks are essential for managing blood sugar levels effectively during illness.

Choice A reason: Activity intolerance related to ischemia is a common concern for clients with AMI, but it is not the primary nursing problem when the client is receiving thrombolytic therapy. The focus should be on monitoring for complications related to the therapy itself.

Choice B reason: Risk for injury related to effects of thrombolytics is the priority nursing problem for a client receiving thrombolytic therapy. Thrombolytics can cause serious bleeding complications, including internal bleeding, hemorrhage at vascular access sites, gastrointestinal bleeding, or intracranial bleeding. The nurse must closely monitor the client for signs and symptoms of bleeding, such as sudden onset or worsening of headache, changes in level of consciousness, hematuria, melena, ecchymosis, or hematoma formation.

Choice C reason: Ineffective breathing pattern related to adverse drug effects can occur following thrombolytic therapy, but it is not the primary concern. The risk of bleeding complications takes precedence as the priority nursing problem for this client.

Choice D reason: Deficient knowledge related to a new medication regimen is important for client understanding and adherence, but it is not the priority nursing problem in the immediate post-thrombolytic therapy period. Ensuring the client's safety by monitoring for bleeding complications is the primary focus.