A nurse is in a provider's office is collecting data from an older adult client who has type 2 diabetes mellitus. Which of the following findings is a manifestation of hyperglycemia?

Correct answer: B

A. Check the gastric residual every 8 hr:
Explanation:It is generally recommended to check gastric residuals more frequently than every 8 hours, often every 4-6 hours, especially in the initial stages of continuous enteral feedings, to monitor tolerance and prevent complications such as aspiration.

B. Change the feeding bag every 24 hr:
Explanation: Changing the feeding bag and tubing at regular intervals helps prevent bacterial contamination and maintain aseptic technique. The frequency of bag changes is typically scheduled every 24 hours or according to facility protocols.

C. Flush the tube with sterile sodium chloride solution every 2 hr:
Explanation:While it is important to flush the feeding tube regularly to maintain patency, using sterile water is typically recommended unless there is a specific clinical indication for sterile sodium chloride. The frequency of flushing (usually every 4-6 hours for continuous feeding) should be determined based on the institution's protocol and the client's specific needs.

D. Position the head of the client's bed at 15 degrees:
Explanation:To reduce the risk of aspiration, the head of the bed should be elevated to at least 30-45 degrees during enteral feedings, not just 15 degrees. Elevating the head of the bed helps prevent reflux and aspiration.

A.Crackles in the lung fields indicate the presence of fluid in the lungs, which can be a sign of pulmonary edema. This is a serious adverse effect of hypertonic saline infusion (3% saline), as it can lead to fluid overload and respiratory compromise.

B.A slightly elevated heart rate (tachycardia) could occur in response to fluid shifts or the underlying condition, but it is not a specific indicator of an adverse outcome related to hypertonic saline infusion.

C.Sediment or blood in the urine is not a typical adverse outcome associated with hypertonic saline infusion. These findings may indicate a separate issue, such as a urinary tract infection or renal impairment, but they are unrelated to the administration of 3% saline for hyponatremia.

D.A rise in blood pressure may be expected as a result of volume expansion due to fluid administration, and it may even be beneficial if the patient was hypotensive.