Exhibits

Based on the client's diagnosis, which results does the nurse expect in the blood gas? Select all that apply

A. Respiratory rate of 26 breaths/minute. A respiratory rate ≥22 breaths/minute meets the SIRS criteria and indicates systemic inflammation or respiratory distress. In pneumonia, increased breathing effort may result from hypoxia or infection-related metabolic demands. Persistent tachypnea suggests worsening sepsis and requires urgent intervention.
B. Heart rate of 112 beats/minute. A heart rate ≥90 beats/minute is a SIRS criterion, often caused by infection, hypoxia, or systemic inflammation. In pneumonia, tachycardia may result from fever, pain, or compensatory mechanisms due to decreased oxygenation. An elevated heart rate in sepsis may indicate progressing hemodynamic instability.
C. Temperature of 96.1° F (35.6°C). Hypothermia (<96.8°F/36°C) is a SIRS criterion and may indicate severe sepsis or systemic inflammatory response. While fever is a common response, low temperature suggests immune system dysfunction. Hypothermia in sepsis is linked to poor prognosis and increased mortality risk.
D. White blood count of 14,000/mm³ (14 x 10⁹/L). A WBC >12,000/mm³ or <4,000/mm³ meets SIRS criteria and indicates infection-related immune activation. Elevated WBCs suggest an active inflammatory response to pneumonia. A rising WBC count may indicate worsening infection or ineffective immune control.
E. Hemoglobin of 12.8 gram/dL (7.94 mmol/L). Hemoglobin levels within the normal range (12-16 g/dL) do not indicate SIRS or sepsis progression. While anemia can develop in chronic illness or bleeding, this value does not contribute to SIRS classification. Monitoring oxygenation and perfusion is more relevant in pneumonia cases.

A. Give the client 15 g of carbohydrates and retest the blood glucose in 15 minutes.
A blood glucose of 250 mg/dL is still high but does not require immediate carbohydrate administration. Carbohydrates are given in cases of hypoglycemia (blood glucose <70 mg/dL) or when transitioning from IV to subcutaneous insulin at lower glucose levels.
B. Bolus the client with 1 L of 3% sodium chloride solution.
The client’s sodium is already elevated (152 mEq/L), and hypertonic saline (3% NaCl) would worsen hypernatremia and increase the risk of neurological complications. Instead, hypotonic fluids (0.45% NaCl) are recommended once intravascular volume is stabilized.
C. Hold the insulin infusion.
HHS is managed with continuous insulin infusion to gradually reduce glucose levels. The blood glucose is still above the target range (250 mg/dL), so insulin should not be stopped prematurely to avoid a rebound in hyperglycemia.
D. Decrease the sodium concentration in the IV fluids from 0.9% to 0.45%.
Once circulatory volume is restored, fluids should be switched to 0.45% sodium chloride to correct hypernatremia and intracellular dehydration. This is a standard part of HHS treatment after initial fluid resuscitation.
E. Alert the provider of the current blood glucose level.
Glucose levels are improving but still high (250 mg/dL), requiring adjustments in fluid and insulin therapy. The provider should be informed to assess whether insulin titration or fluid changes are necessary.
F. Add 20 mEq of potassium chloride to the IV fluids.
Insulin therapy drives potassium into cells, leading to hypokalemia (K⁺ = 3.2 mEq/L), which can cause cardiac arrhythmias and muscle weakness. Potassium replacement is required to prevent complications and maintain normal levels.
G. Start a regular diet.
Clients with HHS require gradual rehydration and glucose control before transitioning to oral intake. A regular diet is not appropriate until the client is stable, glucose levels are consistently controlled, and IV therapy is discontinued.