Ten hours after the client with 50% burns is admitted, her blood glucose level is 142 mg/dL. What is the nurse’s best action?
A. Documents the finding
B. Obtains a family history of diabetes
C. Repeats the glucose measurement
D. Stop IV fluids containing dextrose
Correct Answer: A. Documents the finding
Neural and hormonal compensation to the stress of the burn injury in the emergent phase increases liver glucose production and release. An acute rise in the blood glucose level is an expected client response and is helpful in the generation of energy needed for the increased metabolism that accompanies this trauma.
Option B: A family history of diabetes could make her more of a risk for the disease, but this is not a priority at this time. The secondary assessment shouldn’t begin until the primary assessment is complete; resuscitative efforts are underway; and lines, tubes, and catheters are placed.
Option C: The glucose level is not high enough to warrant retesting. A variety of laboratory tests will be needed within the first 24 hours of a patient’s admission (some during the initial resuscitative period and others after the patient is stabilized).
Option D: The cause of her elevated blood glucose is not the IV fluid. Rapid and aggressive fluid resuscitation is needed to replace intravascular volume and maintain end-organ perfusion.
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