A client with diabetes mellitus is admitted with an upper respiratory infection. Which changes in blood glucose management should the client expect?

Choice A reason: Lifting and clearing drainage from the chest tube is not necessary, as the water level fluctuations indicate that the chest tube is functioning properly and allowing air and fluid to escape from the pleural space.

Choice B reason: Inspecting the tube insertion site for leaking is not indicated, as there is no evidence of air leak in the water-seal chamber. An air leak would cause continuous or intermittent bubbling in the water-seal chamber.

Choice C reason: Continuing to monitor the drainage system is the best action for the nurse to implement, as the water level fluctuations are normal and expected in a water-seal drainage system. The water level should rise during inspiration and fall during expiration, reflecting the changes in intrathoracic pressure.

Choice D reason: Auscultating lungs for unequal breath sounds is not relevant, as it does not address the question of what to do with the water level fluctuations. Unequal breath sounds may indicate a pneumothorax or atelectasis, which are complications of chest trauma or chest tube insertion.

For Potential Conditions:

The correct answer is c) Abdominal compartment syndrome.

Choice A reason: Pneumothorax is a condition where air leaks into the pleural space, causing lung collapse and impaired gas exchange. It can cause respiratory distress, hypoxia, chest pain, and decreased breath sounds on the affected side. However, it does not cause abdominal distension, acidosis, or hyperglycemia.

Choice B reason: Pulmonary embolism is a condition where a blood clot blocks one or more pulmonary arteries, causing impaired gas exchange and reduced blood flow to the lungs. It can cause respiratory distress, hypoxia, chest pain, and tachycardia. However, it does not cause abdominal distension, acidosis, or hyperglycemia.

Choice C reason: Abdominal compartment syndrome is a condition where increased intra-abdominal pressure causes reduced blood flow to the abdominal organs and impaired diaphragm movement. It can cause respiratory distress, hypoxia, abdominal distension, acidosis, decreased urine output, and organ failure. It is a common complication of cirrhosis with ascites.

Choice D reason: Sepsis is a condition where a systemic inflammatory response to an infection causes organ dysfunction and hypoperfusion. It can cause respiratory distress, hypoxia, fever or hypothermia, tachycardia, acidosis, and hyperglycemia. However, it does not cause abdominal distension unless there is an intra-abdominal infection.

The two actions the nurse should take to address abdominal compartment syndrome are:

• Prepare the client for a paracentesis: Paracentesis is a procedure where a needle or catheter is inserted into the peritoneal cavity to drain excess fluid and reduce intra-abdominal pressure.
• Place an intravenous line to start fluid boluses: Fluid boluses are given to maintain adequate blood pressure and perfusion to the vital organs.

The two parameters the nurse should monitor to assess the client’s progress are:

• Oxygen saturation: Oxygen saturation reflects the amount of oxygen bound to hemoglobin in the blood. It should be maintained above 90% to ensure adequate oxygen delivery to the tissues.
• Urine output: Urine output reflects the function of the kidneys and the perfusion of the renal arteries. It should be maintained above 0.5 mL/kg/hour to prevent acute kidney injury and electrolyte imbalances.