A nurse is assessing a client who has a new diagnosis of diabetes mellitus. The nurse should identify that which of the following findings is a manifestation of hyperglycemia?

Rationale:
A. Use an infusion pump to deliver the dialysate at a safe rate: Dialysate for peritoneal dialysis is typically instilled by gravity, not an infusion pump. Using a pump can create excessive pressure, increasing the risk of peritoneal damage or discomfort.

B. Report cloudy dialysate drainage to the provider: Cloudy outflow is a key sign of peritonitis, a serious complication of peritoneal dialysis. This finding should be reported immediately for prompt evaluation and treatment.

C. Warm the dialysate solution using a low power level on a microwave oven: Dialysate should not be warmed in a microwave due to the risk of uneven heating and potential damage to the peritoneal lining. A warming pad or commercial dialysate warmer is recommended to safely bring the solution to body temperature.

D. Allow the dialysate to drain over 1 to 4 hr: The dwell time (the time the dialysate stays in the peritoneal cavity) typically ranges from 30 minutes to a few hours. However, the drainage phase should usually take about 15 to 30 minutes. Allowing dialysate to drain over 1 to 4 hours would be incorrect, as this refers more to dwell time, not the drainage phase.

Rationale:

A. Administer oxygen: The client is experiencing labored respirations and increasing distress. Although their oxygen saturation is currently within normal range, supplemental oxygen is a priority to support oxygenation during this acute episode, especially with signs of anxiety and shortness of breath.

B. Obtain prescription for amiodarone: Amiodarone is used for certain ventricular arrhythmias. The client’s heart rhythm is described as regular, though tachycardic, not indicating a need for amiodarone. This is not an immediate priority without evidence of a specific arrhythmia like ventricular tachycardia.

C. Place client in semi-Fowler's position: Elevating the head of the bed helps reduce the work of breathing and improves lung expansion. This position supports respiratory function, especially when the client is experiencing shortness of breath.

D. Monitor blood pressure every 30 minutes: Blood pressure monitoring is important, but this action is not immediate in the face of worsening symptoms. The client needs more urgent interventions first, including respiratory and cardiac stabilization.

E. Obtain prescription for a beta blocker: The client’s heart rate increased significantly to 170/min and they have a history of poorly controlled hypertension. A beta blocker may be needed to reduce sympathetic overactivity and heart rate, helping to lower blood pressure and myocardial oxygen demand.

F. Monitor for neurologic complications: With a blood pressure of 185/100 mmHg and a worsening severe headache, the client is at risk for neurologic complications such as hypertensive encephalopathy or stroke. Close neurologic monitoring is essential to detect early signs of deterioration.