The nurse is caring for a client with pericarditis after undergoing a bedside pericardiocentesis. Which finding warrants immediate intervention by the nurse?

Rationale:
A. Call the chaplain to encourage the wife to wait outside of the room: While spiritual support is valuable, involving a chaplain does not immediately address the safety and efficiency needs during a life-threatening emergency. Immediate communication with the family is more effective in this situation.

B. Explain that the healthcare team needs space to treat her husband: Clear, calm, and direct communication informs the family member of the critical need for room access and safety during resuscitation. This approach prioritizes patient care while showing respect and empathy for the spouse’s emotions, helping her understand the necessity of leaving temporarily.

C. Ask an administrative supervisor to assist the wife to the waiting area: Involving administration may escalate tension and delay urgent care. While sometimes necessary for compliance issues, this is not the first-line approach during an acute resuscitation.

D. Allow the wife to stay at the bedside with a healthcare team member: Allowing family presence can be supportive in some situations, but during active VF resuscitation, space and immediate access to the patient are critical. Safety and efficiency of the resuscitation take priority.

Rationale:

• Decrease the insulin IV infusion to 0.05 units/kg/hr: The client’s blood glucose levels are steadily decreasing, indicating that the insulin infusion is effective. In HHS, insulin rates are reduced once glucose levels approach the target range to prevent overly rapid declines that can increase the risk of cerebral edema and hypoglycemia. Careful titration supports safe glucose correction.

• Draw electrolyte levels: HHS causes significant osmotic diuresis, leading to electrolyte imbalances, particularly potassium shifts once insulin therapy is initiated. Frequent electrolyte monitoring is necessary to detect and correct abnormalities early and prevent cardiac and neuromuscular complications.

• Change the IV fluids to 0.45% sodium chloride with 5% dextrose: As blood glucose approaches 250–300 mg/dL, dextrose-containing fluids are added to prevent hypoglycemia while allowing continued insulin administration. Hypotonic saline supports ongoing rehydration while avoiding rapid osmolar shifts that could worsen neurologic status.

• Teach the client how to count carbohydrates: Diabetes self-management education is essential but is not a priority during the acute management of HHS. The client is still critically ill and requires stabilization before education can be effective and safely implemented.

• Decrease the frequency of blood glucose tests: Hourly blood glucose monitoring is essential during IV insulin therapy to guide titration and prevent hypoglycemia. Reducing monitoring frequency could delay detection of dangerous glucose changes during this critical phase.

• Start the client on a regular diet: Clients with HHS are typically kept NPO or on limited intake until metabolic stability is achieved. Starting a regular diet prematurely can worsen hyperglycemia and complicate insulin and fluid management.

• Stop the insulin infusion: Insulin infusion must be continued until hyperosmolarity resolves and blood glucose is consistently controlled. Stopping insulin too early can lead to rebound hyperglycemia and delay resolution of HHS.