A client who sustained severe liver lacerations in a motorcycle collision is transported to the intensive care unit (ICU) following a segmental resection of the liver. One hour later, the nurse notes that the client is hemorrhaging from the surgical site. Which action should the nurse take?

Rationale:
A. Bounding erratic pulse: A bounding pulse indicates strong cardiac output, which is inconsistent with ventricular fibrillation, where the ventricles fail to pump effectively.

B. No palpable pulse: Ventricular fibrillation causes chaotic ventricular contractions, preventing effective cardiac output. As a result, the client will have no palpable pulse and will be unresponsive, making this the expected and urgent finding.

C. Thready irregular pulse: A thready, weak, or irregular pulse may occur in severe hypotension or arrhythmias, but VF typically produces no pulse at all due to lack of coordinated ventricular contraction.

D. Regularly irregular pulse: A regularly irregular pulse suggests atrial arrhythmias or other conduction abnormalities but does not correspond to the chaotic, ineffective contractions seen in VF.

Rationale:

• Decrease the insulin IV infusion to 0.05 units/kg/hr: The client’s blood glucose levels are steadily decreasing, indicating that the insulin infusion is effective. In HHS, insulin rates are reduced once glucose levels approach the target range to prevent overly rapid declines that can increase the risk of cerebral edema and hypoglycemia. Careful titration supports safe glucose correction.

• Draw electrolyte levels: HHS causes significant osmotic diuresis, leading to electrolyte imbalances, particularly potassium shifts once insulin therapy is initiated. Frequent electrolyte monitoring is necessary to detect and correct abnormalities early and prevent cardiac and neuromuscular complications.

• Change the IV fluids to 0.45% sodium chloride with 5% dextrose: As blood glucose approaches 250–300 mg/dL, dextrose-containing fluids are added to prevent hypoglycemia while allowing continued insulin administration. Hypotonic saline supports ongoing rehydration while avoiding rapid osmolar shifts that could worsen neurologic status.

• Teach the client how to count carbohydrates: Diabetes self-management education is essential but is not a priority during the acute management of HHS. The client is still critically ill and requires stabilization before education can be effective and safely implemented.

• Decrease the frequency of blood glucose tests: Hourly blood glucose monitoring is essential during IV insulin therapy to guide titration and prevent hypoglycemia. Reducing monitoring frequency could delay detection of dangerous glucose changes during this critical phase.

• Start the client on a regular diet: Clients with HHS are typically kept NPO or on limited intake until metabolic stability is achieved. Starting a regular diet prematurely can worsen hyperglycemia and complicate insulin and fluid management.

• Stop the insulin infusion: Insulin infusion must be continued until hyperosmolarity resolves and blood glucose is consistently controlled. Stopping insulin too early can lead to rebound hyperglycemia and delay resolution of HHS.