Which intervention(s) should the nurse include in the plan of care (POC) for a client who is admitted with hyperosmolar hyperglycemic syndrome (HHS)? Select all that apply.

Rationale:

• Temperature: The client’s temperature is 101.2° F (38.4° C), indicating fever. This is significant because fever in a postoperative adult, especially one who is confused and has a recent knee replacement, may suggest infection or sepsis. Monitoring temperature trends helps identify worsening infection and guides timely interventions such as cultures or antibiotics.

• Heart rate: The client’s heart rate is 126 beats per minute, which is tachycardic. Elevated heart rate can indicate systemic response to infection, dehydration, or stress. In combination with fever and confusion, tachycardia may signal early sepsis or hemodynamic instability. Continuous assessment of heart rate allows the nurse to evaluate the client’s cardiovascular status and response to interventions.

• Respirations: Tachypnea (respirations > 20) is a sensitive early indicator of physiological distress and is one of the criteria used in the qSOFA (quick Sepsis-related Organ Failure Assessment) score to identify clients at risk for poor outcomes.

• Oxygenation: While at the lower limit of normal, an oxygen saturation of 94% is generally considered acceptable for an adult without chronic lung disease and does not require immediate intervention compared to the fever and tachycardia.

• Blood pressure: The blood pressure reading of 118/74 mm Hg is within normal limits and does not currently indicate hypotension or hypertension. While ongoing monitoring is necessary, it is not an urgent concern in this scenario. The combination of fever, tachycardia, and tachypnea takes priority for follow-up.

Rationale:

• Acute kidney injury: The client demonstrates markedly reduced urine output (oliguria), significant weight gain due to edema, and a history of hypovolemic shock with vasopressor support, all of which increase the risk for acute kidney injury. AKI can result from ischemic injury to the kidneys during shock and fluid shifts.

• Measure electrolyte levels: Electrolyte monitoring is essential in AKI, as kidney impairment can cause imbalances in potassium, sodium, and other ions. Detecting changes early prevents complications such as cardiac arrhythmias and neurologic disturbances. Electrolyte trends also guide fluid management and medication dosing.

• Assess lung sounds: Fluid retention from oliguria can lead to pulmonary edema. Assessing lung sounds helps identify crackles, wheezing, or other indications of fluid overload. Early detection allows timely interventions such as adjusting fluid administration or initiating diuretic therapy.

• Daily weight: Daily weight measurement is a reliable indicator of fluid retention or loss. The client’s rapid weight gain reflects edema and fluid accumulation, which correlates with worsening kidney function. Tracking weight trends informs the effectiveness of interventions and fluid management.

• Hemoglobin: Hemoglobin monitoring is important because anemia can occur from hemodilution, blood loss, or renal impairment. Decreased hemoglobin can worsen oxygen delivery to tissues and complicate recovery. Regular assessment ensures timely interventions like transfusions if needed.

• Hypovolemia: The client is demonstrating fluid overload rather than depletion, as evidenced by edema and weight gain. Hypovolemia is characterized by low blood pressure, tachycardia, and reduced perfusion, which are not present here.

• Hemorrhage: There is no active bleeding; the surgical site is intact with no drainage. Hemorrhage would present with hypotension, tachycardia, and signs of blood loss, which are absent.

• Septic shock: The client is afebrile, hemodynamically stable on this day, and without signs of infection. Although sepsis can cause oliguria, the current presentation is more consistent with post-shock AKI rather than systemic infection.

• Hold pressure on the surgical site: The surgical site is intact with no active bleeding, so applying pressure is unnecessary and would not affect AKI.

• Give 1,000 mL of isotonic solution IV: Excessive fluid administration could worsen edema and fluid overload in AKI. Careful fluid balance is required rather than liberal IV fluid boluses.

• Alert the rapid response team: The client is stable on the current assessment; there are no acute deterioration signs necessitating immediate rapid response activation.

• Capillary refill: While capillary refill assesses perfusion, this client’s perfusion is adequate. It is not a sensitive indicator for ongoing AKI or fluid overload.

• Surgical site drainage: There is no active drainage or bleeding; monitoring the site is routine but not a primary parameter for AKI.

• Electrocardiogram: ECG monitoring may be indicated for electrolyte disturbances, but daily monitoring is not the first-line parameter unless arrhythmias are suspected. Daily lab and clinical monitoring are more direct indicators.