A nurse is caring for a client in the emergency department.

Exhibits here

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1400:

Client admitted to the medical-surgical unit at 1200 today. Alert and orientated x4, heart and lung sounds clear. Client urinating 100 mL/hour.

Client is tolerating soft diet and oral fluids. Bowel sounds are hyperactive in all 4 quadrants.

Bilateral pedal pulses 2+, Blood glucose 310 mg/dl. (74 to 106 mg/dL) 1400:

Temperature 36.8° C (98.2° F)

Pulse rate 84/min Respiratory rate 16/min

Blood pressure 106/76 mm Hg Oxygen saturation 96% on room air

A) While wearing an N95 respirator may be necessary for certain infections, it is not a routine precaution for clients in protective isolation.
B) Ensuring the client's room has positive-pressure airflow helps prevent the entry of airborne pathogens into the room, reducing the risk of infection for the immunocompromised client.
C) Using disposable plates and utensils helps reduce the risk of cross-contamination and infection transmission but is not directly related to airborne infection control.
D) Monitoring the client's temperature is important for assessing for signs of infection, but it does not directly prevent infection transmission in the same way as positive-pressure airflow.

A. This prescription addresses hypokalemia. Potassium chloride is administered intravenously to help normalize potassium levels within the desired range. However, in this case the patient’s potassium is 5.5 hence does not require potassium chloride.

B. The client has mild hyperkalemia; hence, continuous cardiac monitoring is prudent to detect any potential arrhythmias or changes in cardiac status. However, the priority interventions are insulin therapy, hydration, and urinary catheter insertionto monitor input and output.

C. Subcutaneous insulin administration may be appropriate for clients with diabetes mellitus, but in this case, the client's blood glucose level is critically high, and they may be experiencing diabetic ketoacidosis (DKA), which requires rapid correction. Subcutaneous insulin administration would not provide the prompt and aggressive treatment required for DKA.

D. This prescription addresses the client's hyperglycemia and acidosis indicated by the blood glucose level of 468 mg/dL and pH of 7.30, respectively. Continuous intravenous insulin infusion is the standard treatment for diabetic ketoacidosis (DKA) to lower blood glucose levels and correct acidosis.

E. This prescription addresses the client's dehydration indicated by the elevated blood glucose level, decreased blood pressure, and slight tenting of the skin. Intravenous fluid resuscitation with 0.9% sodium chloride is initiated to restore intravascular volume and correct electrolyte imbalances.

F. Administering D5W intravenously is contraindicated in the setting of hyperglycemia and diabetic ketoacidosis (DKA) because it would exacerbate the already elevated blood glucose levels. D5W contains glucose and would further increase blood glucose levels, worsening the client's condition.

G. While monitoring blood glucose levels is important for clients with diabetes, checking it every 4 hours is not sufficient in this scenario, especially given the client's markedly elevated blood glucose level of 468 mg/dL and symptoms suggestive of diabetic ketoacidosis (DKA). Therefore, blood glucose levels should be monitored at least hourly.

H. Monitoring urine output is important in clients with diabetes and dehydration. Therefore, inserting an indwelling urinary catheter is important in this scenario.