A nurse assesses a client with diabetes mellitus 3 hours after a surgical procedure and notes the client's breath has a "fruity" odor. Which action should the nurse take?

Choice A rationale: An elevated temperature in a patient with Grave's disease, a form of hyperthyroidism, can be an early sign of a life-threatening condition called thyroid storm or thyrotoxic crisis. This is a severe, acute exacerbation of hyperthyroidism characterized by extreme hypermetabolism. The body's inability to cope with this heightened metabolic state leads to fever, tachycardia, severe hypertension, and potential heart failure, requiring immediate medical intervention to stabilize the patient. Normal body temperature is around 36.5-37.5°C (97.7-99.5°F).
Choice B rationale: Elevated blood pressure is a common finding in hyperthyroidism due to increased cardiac output and peripheral vasodilation. While it is a significant finding that requires monitoring and management, it does not typically pose the immediate, life-threatening risk that a sudden and marked elevation in body temperature suggests, which is a hallmark of an impending thyroid storm. Normal blood pressure is <120/80 mmHg.
Choice C rationale: A change in respiratory rate, such as an increase, can be associated with the hypermetabolic state of hyperthyroidism. However, it is a less specific and often less immediate indicator of a thyrotoxic crisis than a fever. While respiratory distress can occur, especially in severe cases, the elevated temperature is a more direct and urgent sign of systemic decompensation. Normal respiratory rate is 12-20 breaths per minute.
Choice D rationale: Irregular heart rate and rhythm, particularly atrial fibrillation, are frequent complications of hyperthyroidism. The excess thyroid hormone sensitizes the heart to catecholamines, leading to arrhythmias. While this requires careful management to prevent complications like stroke, it is a chronic manifestation. A new or sudden onset of fever is a more acute and urgent indicator of a potentially fatal crisis. Normal heart rate is 60-100 bpm.

Choice A rationale: Peripheral neuropathy and decreased circulation make the feet of a person with diabetes susceptible to injury and infection. Walking barefoot increases the risk of stepping on sharp objects or sustaining cuts, which may go unnoticed due to sensory loss. Proper footwear is essential to protect the feet from injury.
Choice B rationale: Soaking the feet, especially in hot water, can lead to maceration of the skin, making it more prone to fungal infections and breakdown. Due to nerve damage, a client with diabetes may not accurately perceive water temperature, risking burns. It is recommended to wash the feet with lukewarm water and pat them dry.
Choice C rationale: Trimming toenails straight across prevents ingrown toenails, a common source of foot infections. Ingrown nails can cause skin breakdown, creating an entry point for bacteria. Diabetic clients should avoid cutting the nails in a curved fashion to prevent this complication and should be cautious to avoid cutting the cuticles.
Choice D rationale: Epsom salts are a magnesium sulfate solution. They can be very drying to the skin, which is already prone to cracking in diabetic individuals, increasing the risk of infection. Furthermore, they are not an effective treatment for blisters or sores and could exacerbate the problem by irritating the skin.
Choice E rationale: Washing the feet every day is crucial for maintaining hygiene and inspecting for any cuts, sores, or changes. Daily washing with mild soap and lukewarm water helps prevent bacterial and fungal infections. Waiting until every other day to wash the feet increases the risk of infection.