Exhibits

Complete the diagram by choosing from the choices below to specify which condition the client is most likely experiencing, two actions the nurse should take to address the condition, and two parameters the nurse should monitor to assess the client's progress.

Choice A reason: Preparing the prescribed dose of rapid-acting insulin from the sliding scale instructions is not appropriate when the client's blood glucose level is low (56 mg/dL). Administering insulin at this point could further lower the blood glucose level, potentially leading to severe hypoglycemia. The priority is to raise the client's blood glucose level to a safe range.

Choice B reason: Giving the client six ounces of non-diet carbonated soda and instructing the client to drink it entirely is the correct first intervention. The client’s blood glucose level is significantly below the normal reference range (hypoglycemia). Administering a fast-acting carbohydrate, such as non-diet soda, helps to quickly increase the blood glucose level to a safer range. This intervention addresses the immediate need to correct the hypoglycemia and prevent potential complications such as confusion, seizures, or loss of consciousness.

Choice C reason: Collecting a blood specimen by venipuncture to send to the laboratory for serum glucose analysis is not the first intervention to implement. While laboratory confirmation of blood glucose levels can be important, the immediate priority is to treat the hypoglycemia. Delaying treatment to collect a laboratory specimen could result in worsening of the client's condition. Immediate administration of a fast-acting carbohydrate should be prioritized.

Choice D reason: Documenting the glucose reading in the electronic medical record (EMR) is important but not the first priority. While accurate documentation is necessary for ongoing care, the immediate intervention should focus on treating the hypoglycemia. Once the client's blood glucose level has been stabilized, the nurse can then document the reading and subsequent interventions in the EMR.

Choice A reason: Polyuria and excessive thirst are classic symptoms of diabetes insipidus and indicate the body's inability to retain water due to a lack of antidiuretic hormone (ADH). While these symptoms need to be managed, they are not immediately life-threatening compared to severe hypernatremia.

Choice B reason: A serum sodium level of 185 mEq/L (185 mmol/L) indicates severe hypernatremia, which is an immediate medical emergency. Severe hypernatremia can lead to neurological symptoms such as confusion, seizures, and even coma due to the osmotic shift of water out of brain cells. Immediate intervention is required to correct the sodium imbalance and prevent serious complications.

Choice C reason: An apical heart rate of 110 beats per minute is indicative of tachycardia, which can be associated with dehydration and the body's response to maintain cardiac output. While it is a concern, it does not take precedence over the need to address severe hypernatremia.

Choice D reason: Dry skin with inelastic turgor is a sign of dehydration, which is a common issue in diabetes insipidus due to excessive fluid loss. While this requires attention, it is not as immediately critical as addressing severe hypernatremia, which poses a direct and urgent threat to the client's neurological and overall health.