The nurse is caring for a patient with diabetes. Exhibits The nurse is preparing to speak with the provider regarding the client's condition. Which of the following orders should the nurse anticipate? Select all that apply.
Explanation & Rationale
A. Oxygen at 2 liters via nasal cannula is not indicated as the patient’s oxygen saturation is within normal limits. There is no evidence of hypoxia or respiratory compromise to justify supplemental oxygen. B. Tylenol 650 mg po every 6 hours prn pain is unnecessary at this time because the patient denies pain. Giving medication without indication can mask emerging symptoms or cause side effects. C. Capillary blood glucose (CBG) before meals and at bedtime ensures tight glucose monitoring and guides insulin adjustments. Frequent checks help prevent hypoglycemia and track the effectiveness of IV insulin. D. Regular insulin IV is critical for reversing diabetic ketoacidosis by reducing hyperglycemia and halting ketone production. Continuous infusion allows for precise titration to correct acidosis and prevent complications. E. Measure intake and output every shift is necessary due to fluid losses from polyuria and vomiting. Monitoring helps detect dehydration and guides fluid replacement to stabilize hemodynamics. F. Repeat urinalysis in the morning helps track ketone clearance and monitor renal involvement. It supports clinical decision-making about progression or resolution of the DKA episode. G. Calorie count is important to assess nutritional intake, especially as the patient has had recent weight loss. It supports recovery and helps tailor dietary adjustments post-stabilization. H. Ambulate with assistance is unsafe due to hypotension and dehydration, which increase fall risk. The patient should remain on bedrest until volume status and perfusion are stabilized.