A nurse is reviewing the medical history on a client who is preoperative for surgery.
Which of the following findings places the client at risk for a postoperative complication?

Choice A rationale

Encouraging increased oral fluid intake is an inappropriate intervention for a confused client with a blood glucose of 42 mg/dL. While fluids are important, the priority is to raise the blood glucose level immediately. Furthermore, confusion increases the risk of aspiration, making the oral route dangerous if the client cannot protect their airway. Simple water intake does nothing to address the underlying neuroglycopenia. Treatment must focus on rapidly delivering glucose through concentrated sources to restore brain function.

Choice B rationale

Emergency dialysis is used for life-threatening electrolyte imbalances, such as severe hyperkalemia, or for clearing specific toxins and managing end-stage renal disease. It has no role in the management of acute hypoglycemia. The client’s confusion and diaphoresis are caused by a lack of circulating glucose, not the buildup of uremic waste products. Preparing for dialysis would delay the life-saving administration of glucose and would be an irrelevant and potentially harmful diversion of medical resources.

Choice C rationale

Administering 50 percent dextrose (D50) intravenously is a priority intervention for a client who is symptomatic and has a blood glucose level as low as 42 mg/dL. Because the client is confused, oral glucose is unsafe due to the risk of aspiration. D50 provides a concentrated bolus of glucose that rapidly increases serum levels, providing the brain with the necessary fuel to regain consciousness and stop the neuroglycopenic symptoms. This is a standard emergency protocol for severe hypoglycemia.

Choice D rationale

Rechecking the blood glucose 15 minutes after an intervention is a critical step in the "15-15 rule" of hypoglycemia management. After administering a glucose source, the nurse must evaluate the effectiveness of the treatment to ensure the level is rising appropriately toward the normal range of 70 to 110 mg/dL. This allows for the timely administration of a second dose if the glucose remains low. Continuous monitoring is essential until the client is stable and their mental status clears.

Choice E rationale

Administering an IV insulin infusion is strictly contraindicated for a client with a blood glucose of 42 mg/dL. Insulin works by moving glucose from the bloodstream into the cells, which would further lower the serum glucose and could lead to seizures, permanent brain damage, or death. Insulin is used to treat hyperglycemia, not hypoglycemia. The goal in this scenario is to raise the glucose level, so any administration of insulin would be a fatal medical error in this context.

Choice A rationale

A potassium level of 5.0 mEq/L is at the high end of the normal range, which is typically 3.5 to 5.0 mEq/L. While this is a normal finding, it does not specifically indicate that the interventions for pulmonary edema and fluid overload are effective. Furosemide is a loop diuretic that usually causes potassium loss. A stable potassium level is good, but it is not the primary clinical indicator that the fluid in the lungs has been successfully cleared.

Choice B rationale

A weight gain of 1 pound (0.5 kg) indicates that the patient is retaining fluid rather than losing it. In the context of pulmonary edema and IV Furosemide therapy, the goal is diuresis and weight loss. Effective treatment should result in a decrease in weight as excess interstitial and intravascular fluid is excreted by the kidneys. A gain suggests that the heart is still struggling to pump effectively or that the diuretic dose is insufficient to manage the overload.

Choice C rationale

A heart rate of 110 BPM indicates tachycardia, which is often a compensatory mechanism for decreased cardiac output or respiratory distress in pulmonary edema. A normal adult heart rate ranges from 60 to 100 BPM. An elevated heart rate suggests that the patient's cardiovascular system is still under significant stress. Effectiveness of treatment would be better demonstrated by a heart rate returning to the normal range as oxygenation improves and the fluid volume in the vasculature decreases.

Choice D rationale

Clear lung sounds are a definitive indicator that the interventions for pulmonary edema are working. Pulmonary edema involves the accumulation of fluid in the alveoli, which produces crackles or rales upon auscultation. Furosemide works to remove this excess fluid, while the Semi-Fowler's position improves lung expansion and gas exchange. When the nurse hears clear lung sounds, it signifies that the fluid has been cleared from the alveolar spaces, directly demonstrating the success of the treatment.