A patient with type 1 Diabetes Mellitus is admitted to the medical unit with an acute exacerbation of chronic obstructive pulmonary disease.

He is placed on IV piggyback antibiotics, nebulizer treatments with albuterol, and an IV corticosteroid, and he is also taking a proton pump inhibitor for gastroesophageal reflux disease.
He takes a dose of glargine insulin every evening.

This evening the nurse notes that his blood glucose level is 170 mg/dL. The next morning, his fasting glucose level is 202 mg/dL. What is the most likely cause of his elevated glucose levels?

Choice A rationale

D5W (dextrose 5% in water) is an isotonic solution in the bag but becomes hypotonic in the body as dextrose is metabolized, leading to free water redistribution. This fluid is not ideal for dehydration as it does not contain electrolytes and can potentially dilute existing electrolytes, which is counterproductive for replacing lost volume and salts.

Choice B rationale

0.9% normal saline is an isotonic solution, meaning it has a similar concentration of solutes to the body's plasma. It is the most appropriate choice for treating dehydration, as it replenishes both fluid volume and sodium chloride, which are commonly lost during dehydration, effectively expanding the intravascular compartment without causing major fluid shifts.

Choice C rationale

0.45% saline, or half-normal saline, is a hypotonic solution with half the sodium concentration of normal saline. This fluid is used to replace free water deficits and for hypernatremia, but it is not the first-line choice for general dehydration as it does not effectively expand the intravascular volume and can cause fluid shifts into cells.

Choice D rationale

Packed red blood cells (PRBCs) are blood products used for anemia or significant blood loss to increase oxygen-carrying capacity. They are not a fluid replacement for dehydration. Administering blood when it's not clinically indicated for fluid volume deficit is inappropriate and carries risks of transfusion reactions and fluid overload.

Choice A rationale

Increasing fluid intake is not the appropriate action for muscle cramps caused by a thiazide diuretic. Thiazide diuretics, such as hydrochlorothiazide, work by inhibiting sodium and chloride reabsorption in the distal convoluted tubule. This increases water excretion. The muscle cramps are related to electrolyte imbalances, not a lack of hydration.

Choice B rationale

Discontinuing the medication immediately is not the first step and requires a provider's order. The nurse's initial action should be to gather data to confirm the cause of the cramps. If the cramps are related to hypokalemia, discontinuing the medication without provider consultation could lead to other complications and is not within the nurse's scope of practice.

Choice C rationale

Thiazide diuretics cause the excretion of sodium, chloride, and potassium from the kidneys, leading to hypokalemia. The normal potassium range is 3.5 to 5.0 mEq/L. Muscle cramps are a classic symptom of hypokalemia. The nurse should check the patient's serum potassium levels to confirm the suspected electrolyte imbalance and inform the provider for further management, such as a potassium supplement.

Choice D rationale

While regular exercise is beneficial for overall health, encouraging more exercise would not address the underlying cause of the muscle cramps related to the medication's effect on electrolytes. In fact, intense exercise could worsen the situation by causing further fluid and electrolyte loss through sweating.