The nurse assumes care of a postoperative adult client with type 2 diabetes mellitus and learns that the client has a current blood glucose level of 750 mg/dL (42 mmol/L). When assessing the client, which is the priority? Reference Range: Glucose [Reference Range:74 to 106 mg/dL (4.1 to 5.9 mmol/L)]

Rationale: A. Observe wound drainage characteristics: Monitoring surgical wound drainage is not the immediate priority in the presence of a critically elevated blood glucose level. Hyperglycemia can impair wound healing, but signs of dehydration and fluid loss pose more immediate life-threatening concerns. B. Assess for signs of fluid volume deficit: With a glucose level of 750 mg/dL, the client is at high risk for hyperosmolar hyperglycemic state (HHS), which causes severe dehydration due to osmotic diuresis. Assessing for fluid volume deficit is the priority to prevent hypovolemic shock and end-organ damage. C. Determine when the client last ate: Knowing the time of last oral intake is useful in evaluating glucose trends, but it does not take precedence over assessing for the physiological effects of extreme hyperglycemia, such as dehydration and altered mental status. D. Measure the level of acute pain: Pain assessment is essential in postoperative care, but it is not the top priority when blood glucose is dangerously high. Uncontrolled hyperglycemia can cause more rapid deterioration and must be assessed and managed first.