A client is admitted to the intensive care unit (ICU) with sepsis and acute respiratory distress syndrome (ARDS). The client is orally intubated and mechanically ventilated. Which intervention is most important for the nurse to include in the client's plan of care (POC)?

A. Give the client 15 g of carbohydrates and retest the blood glucose in 15 minutes.
A blood glucose of 250 mg/dL is still high but does not require immediate carbohydrate administration. Carbohydrates are given in cases of hypoglycemia (blood glucose <70 mg/dL) or when transitioning from IV to subcutaneous insulin at lower glucose levels.
B. Bolus the client with 1 L of 3% sodium chloride solution.
The client’s sodium is already elevated (152 mEq/L), and hypertonic saline (3% NaCl) would worsen hypernatremia and increase the risk of neurological complications. Instead, hypotonic fluids (0.45% NaCl) are recommended once intravascular volume is stabilized.
C. Hold the insulin infusion.
HHS is managed with continuous insulin infusion to gradually reduce glucose levels. The blood glucose is still above the target range (250 mg/dL), so insulin should not be stopped prematurely to avoid a rebound in hyperglycemia.
D. Decrease the sodium concentration in the IV fluids from 0.9% to 0.45%.
Once circulatory volume is restored, fluids should be switched to 0.45% sodium chloride to correct hypernatremia and intracellular dehydration. This is a standard part of HHS treatment after initial fluid resuscitation.
E. Alert the provider of the current blood glucose level.
Glucose levels are improving but still high (250 mg/dL), requiring adjustments in fluid and insulin therapy. The provider should be informed to assess whether insulin titration or fluid changes are necessary.
F. Add 20 mEq of potassium chloride to the IV fluids.
Insulin therapy drives potassium into cells, leading to hypokalemia (K⁺ = 3.2 mEq/L), which can cause cardiac arrhythmias and muscle weakness. Potassium replacement is required to prevent complications and maintain normal levels.
G. Start a regular diet.
Clients with HHS require gradual rehydration and glucose control before transitioning to oral intake. A regular diet is not appropriate until the client is stable, glucose levels are consistently controlled, and IV therapy is discontinued.

A. Obtain a chest x-ray to verify endotracheal tube location. A chest x-ray is the gold standard for confirming ETT placement, but it is not the first step. Immediate bedside assessment is needed to ensure the tube is correctly positioned before relying on imaging. If the tube is misplaced in the esophagus, waiting for an x-ray could delay necessary corrections.
B. Call the respiratory therapist (RT) to verify tube placement. The nurse should first perform a rapid bedside assessment before consulting the RT. While RTs assist in confirming placement, the nurse is responsible for the initial verification of breath sounds, chest rise, and end-tidal CO₂ (ETCO₂) readings. Any concerns should be addressed immediately.
C. Instill normal saline into the endotracheal tube for suctioning. Instilling saline before suctioning is not recommended, as it can promote aspiration, decrease oxygenation, and increase infection risk. The priority is confirming that the tube is properly placed before performing any interventions such as suctioning.
D. Auscultate for breath sounds bilaterally in all lung fields. The first action after ETT placement is to auscultate bilateral breath sounds to confirm proper tube positioning. If the tube is misplaced in the esophagus, breath sounds will be absent or diminished bilaterally. If placed too deep, breath sounds may be absent on one side, indicating mainstem bronchus intubation. This immediate assessment helps identify misplacement before obtaining a chest x-ray.