The nurse is caring for a patient with diabetes. Exhibits Which of the following actions should the nurse take? Select all that apply.

A. Assess bowel sounds: The patient’s abdomen is soft with hypoactive bowel sounds, which may indicate gastrointestinal hypomotility or early ileus secondary to metabolic derangement or infection. Monitoring bowel sounds is critical for detecting potential complications and guiding treatment. B. Obtain blood glucose from the lab: Laboratory glucose measurement confirms bedside findings and helps evaluate trends, ensuring accurate assessment of glycemic status in a critically hypoglycemic patient. C. Obtain temperature: Elevated white blood cell count and history of recent illness raise concern for infection, which can precipitate metabolic instability in diabetes. Monitoring temperature aids in identifying infectious processes requiring intervention. D. Obtain pulse oximeter: The patient has diminished lung sounds despite oxygen therapy at 2 L/min, suggesting possible respiratory compromise. Continuous pulse oximetry is essential for monitoring oxygenation status. E. Stop insulin drip: The patient’s blood glucose of 40 mg/dL indicates severe hypoglycemia; continuing insulin at this point risks worsening neuroglycopenia and potentially fatal outcomes. Immediate cessation of insulin is necessary. F. Administer dextrose: IV dextrose administration is the primary treatment for severe hypoglycemia, especially in a lethargic patient unable to take oral carbohydrates. This intervention rapidly restores serum glucose and prevents neurological damage. G. Assess neurological status: Lethargy reflects central nervous system impairment from hypoglycemia. Ongoing neurological assessment is crucial to monitor progression and response to treatment.