A nurse is caring for a client who has type 2 diabetes mellitus. Which of the following findings should the nurse identify as manifestations of hypoglycemia?

Rationale

A. Keep the head of the client's bed at 30° or less: Elevating the head of the bed to 30° or less reduces pressure on the sacrum and heels, which are common sites for pressure injury in immobile clients. Maintaining this position helps prevent shear and friction forces that contribute to skin breakdown.

B. Bathe the client with soap and hot water: Using soap and hot water can strip natural oils from the skin, increasing dryness and the risk of breakdown. Gentle cleansing with lukewarm water and mild, pH-balanced soap is recommended to preserve skin integrity.

C. Slide the client up in bed every 2 hr: Sliding the client up in bed creates shear and friction forces on the skin, which can exacerbate pressure injuries. Repositioning should involve lifting or using a draw sheet to move the client safely without dragging the skin.

D. Massage bony prominences four times daily: Massaging bony prominences can damage underlying tissue and worsen skin breakdown. Pressure should be relieved through repositioning and support surfaces rather than direct massage of high-risk areas.

Rationale

A. Instruct the client to use the incentive spirometer five times per hour: Frequent use of the incentive spirometer promotes lung expansion, prevents atelectasis, and improves oxygenation postoperatively, especially when lung sounds are diminished.

B. Administer ondansetron: Ondansetron addresses nausea but does not directly improve respiratory status. While important for comfort, it is not a primary intervention for pulmonary function.

C. Encourage the client to splint the abdomen: Splinting the incision during coughing or deep breathing reduces pain, allowing the client to perform respiratory exercises effectively and decrease the risk of atelectasis or hypoventilation.

D. Encourage the client to cough and breathe deeply: Deep breathing and coughing mobilize secretions, enhance alveolar ventilation, and prevent postoperative pulmonary complications, which is critical given the client’s diminished lung sounds and shallow respirations.

E. Administer supplemental oxygen: Supplemental oxygen can help improve oxygen saturation in clients with hypoxemia, as indicated by the drop to 92% on room air.

F. Ambulate the client 30 min after administering analgesia: Early ambulation enhances lung expansion, promotes circulation, and helps prevent pulmonary complications. Providing analgesia beforehand minimizes pain and encourages participation.

G. Administer acetaminophen: Acetaminophen may reduce fever and mild pain but does not directly improve respiratory status or lung expansion, so it is not a primary intervention in this scenario.