The nurse is caring for a patient with diabetes. Exhibits Exhibits Only choose one option (anticipated, nonessential, contraindicated) for each potential order. Each option will be used at least once.
Explanation & Rationale
Check Urinalysis in the morning: Ongoing urine monitoring remains essential to assess resolution of ketonuria and metabolic status as the patient stabilizes. It guides further management decisions during recovery. Maintain NPO: At this stage of clinical stability (CBG 140) and normal vital signs, continuing NPO is nonessential; the patient may tolerate oral intake as metabolic control improves and nausea subsides. Early nutritional support can aid recovery. Physical therapy consult: A physical therapy consult is not an immediate priority for a client in the acute phase of DKA. The client is still recovering from a serious metabolic emergency, requiring stabilization of fluid, electrolyte, and glucose balance. Insert a urinary catheter: Catheterization is contraindicated without specific indications due to infection risk and patient mobility considerations, especially as he is alert and stable. IV Dextrose 5% with NS at 100 ml/hr: With the patient’s blood glucose now lowered to 140 mg/dL on insulin drip, administering IV dextrose prevents hypoglycemia while continuing insulin to clear residual ketoacidosis. This is standard care once glucose approaches normal levels.