A client was successfully extubated after several days of sedation and mechanical ventilation and is currently receiving 40% oxygen via a face mask. While making rounds, the nurse finds the client confused and attempting to get out of bed. Current vital signs are an oral temperature 99.2°F (37.3° C), heart rate 112 beats/minutes, respirations 16 breaths/minute, blood pressure 100/70 mm Hg, and an oxygen saturation of 98%. Which intervention should the nurse implement?

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. Respirations are shallow, labored, and 14 breaths/minute. A C5 spinal cord injury can impair diaphragmatic function and respiratory effort, leading to respiratory failure. Shallow and labored breathing suggests that the client is experiencing respiratory compromise, which can quickly progress to hypoventilation, hypoxia, and respiratory arrest. Immediate intervention, such as assisted ventilation or intubation, may be necessary to maintain adequate oxygenation and prevent further complications.
B. Has flaccid upper and lower extremities. Flaccid paralysis is an expected finding immediately after a high spinal cord injury due to spinal shock. While this condition requires ongoing monitoring, it is not an immediate life-threatening emergency like respiratory distress.
C. Blood pressure is 110/70 mm Hg and the apical heart rate is 68 beats/minute. These vital signs are within normal limits and do not indicate hemodynamic instability. Neurogenic shock, which can occur with high spinal injuries, typically presents with hypotension and bradycardia, but this client’s current BP and HR are stable.
D. Is unable to feel sensation in the arms and hands. Loss of sensation is expected with a cervical spinal cord injury due to nerve pathway disruption. While this finding is significant, it does not require immediate intervention compared to respiratory distress, which is the most urgent priority.