0700 - Handoff report received. On assessment, the client’s breathing appears regular without any distress, and clear lung sounds are noted in all lung fields. Skin is warm to the touch and pink in tone; pulses 2+ and regular. Capillary refill is 3 seconds. Client is alert and oriented to person, place, and time. Two peripheral venous access devices (VAD) were noted in the right and left antecubital spaces. The right VAD had 0.9% saline infusing at 100 mL/hr, and the left had regular insulin infusing at 4 units/hr.
- Continuous infusion of regular insulin per DKA protocol
- 0.9% saline at 100 mL/hr
- Basic metabolic panel (BMP) every 3 hours
- Obtain capillary blood glucose hourly
- Daily complete blood counts (CBC)
The nurse reviews the physician's orders and plans care
➢ Complete the sentences below from the list of options
The nurse understands that the [complete blood count / basic metabolic panel / capillary blood glucose] needs to be monitored due to the client's risk for [hyperglycemia / hypokalemia / hemoconcentration]
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