A nurse is caring for an older adult client who is 1 hr postoperative following a transurethral resection of the prostate and is receiving continuous bladder irrigation. Which of the following findings should the nurse report to the provider?

A. Blood glucose level: The client’s blood glucose is 103 mg/dL, which is within normal limits. While monitoring glucose is important for a client with diabetes, this finding does not require immediate follow-up in acute chest pain and suspected myocardial infarction.

B. Bowel sounds: Bowel sounds are present in all four quadrants, indicating normal gastrointestinal function. This assessment is routine and does not necessitate urgent follow-up compared with cardiovascular concerns.

C. Blood pressure: The client’s blood pressure is 164/80 mm Hg, indicating hypertension. Elevated blood pressure can increase myocardial oxygen demand and worsen cardiac ischemia, making it important to address immediately.

D. Pain level: The client reports chest tightness rated 7/10 with radiation to the left arm and associated nausea and diaphoresis. This presentation is characteristic of acute myocardial infarction and requires immediate intervention to reduce myocardial damage and prevent complications.

E. Electrocardiogram findings: The ECG shows tachycardia with ST-segment elevation and T-wave changes, indicating myocardial injury or infarction. Immediate follow-up is critical to initiate reperfusion therapy and prevent further cardiac damage.

F. Lung sounds: Lungs are clear to auscultation, which is expected and does not indicate acute respiratory compromise. No immediate follow-up is required in this context.

G. Troponin T level: Troponin T is elevated at 0.40 ng/mL, confirming myocardial injury. This requires urgent follow-up to guide treatment and assess the extent of cardiac damage.

A. Initiate cardiac monitoring: Cardiac monitoring is important because the client has hyperkalemia (potassium 5.5 mEq/L) and is at risk for arrhythmias. Monitoring allows early detection of changes in cardiac rhythm, which can occur rapidly in electrolyte imbalances associated with hyperglycemic crises.

B. Potassium chloride 20 mEq/L intravenous PRN potassium less than 5.0 mEq/L: Potassium replacement is not indicated at this time because the client’s serum potassium is elevated at 5.5 mEq/L. Administering potassium now could worsen hyperkalemia and increase the risk of life-threatening cardiac dysrhythmias.

C. Regular insulin 20 units subcutaneously: Subcutaneous insulin is not appropriate for severe hyperglycemia with ketoacidosis risk, as it has a slower onset and may not provide adequate glycemic control. Intravenous insulin infusion is preferred in this setting to allow rapid titration and prompt reduction of blood glucose and ketone levels.

D. 0.9% sodium chloride at 15 ml/kg/hr for 1 hr and then reduce to 10 ml/kg/hr: Aggressive IV fluid resuscitation with isotonic saline is indicated for dehydration from hyperglycemia and osmotic diuresis. Calculated fluid replacement helps restore intravascular volume, improve perfusion, and support renal function.

E. Dextrose 5% in water (D5W) intravenous at 5 ml/kg/hr for 4 hr: Dextrose is not indicated initially because the client’s blood glucose is extremely elevated at 468 mg/dL. Dextrose would worsen hyperglycemia at this stage. Dextrose is added later during insulin therapy when glucose levels fall to prevent hypoglycemia while continuing ketone clearance.

F. Insert indwelling urinary catheter: Routine catheterization is not indicated for this client, as there is no urinary retention or obstruction reported. Inserting a catheter unnecessarily increases the risk of infection without improving outcomes in hyperglycemia management.

G. Blood glucose checks every 4 hr: For a client with severe hyperglycemia and suspected DKA or hyperosmolar state, glucose monitoring every 4 hours is insufficient. Hourly monitoring is needed to safely titrate IV insulin and fluids, allowing rapid response to changing glucose and electrolyte levels.

H. Regular insulin continuous intravenous infusion, titrate per diabetic ketoacidosis (DKA) protocol once potassium is greater than 3.3 mEq/L: Continuous IV insulin infusion is the treatment of choice for severe hyperglycemia with ketones and acidosis. It allows precise titration based on glucose levels while ensuring potassium levels are safe.