An adult client with a history of severe inflammatory bowel disease is receiving continuous total parenteral nutrition (TPN) through a peripherally inserted central catheter (PICC). The practical nurse evaluates the morning laboratory results and identifies a serum glucose level of 415 mg/dL (23.0 mmol/L). During the morning assessment, the client appears lethargic, and the vital signs reveal a heart rate of 114 beats/minute and a blood pressure of 94/56 mm Hg. Which action must the practical nurse implement first?
- AHold the report of the abnormal glucose level until the healthcare provider arrives for scheduled morning rounds.
- BContinue routine monitoring since mild hypotension and tachycardia are expected fluid shifts associated with nutrition therapy.
- Notify the registered nurse immediately regarding the critical laboratory value and the current vital signs.Answer
- DAdminister an intravenous push of regular insulin to rapidly correct the client's elevated blood glucose.
Answer
The correct action is to notify the registered nurse immediately regarding the critical laboratory value and the current vital signs.
The client is exhibiting signs of severe hyperglycemia paired with potential hypovolemia (tachycardia and borderline hypotension), likely resulting from osmotic diuresis. A blood glucose level of 415 mg/dL is a critical value that poses an immediate risk to the client's safety. The priority action for the practical nurse, in accordance with risk reduction principles and their scope of practice, is to urgently communicate these critical findings to the registered nurse. The RN will then complete a comprehensive assessment and coordinate necessary medical interventions with the healthcare provider.
Step-by-Step Solution
Key Concept
Recognizing and escalating critical laboratory values and signs of physiological instability