Three hours after surgery, the nurse notes that the breath of the client with type 1 diabetes has a "fruity" odor. Which is the nurse's best first action?
a. Document the finding in the client's chart.
b. Increase the IV fluid flow rate.
c. Test the serum for ketone bodies.
d. Perform pulmonary hygiene.
C
The stress of surgery increases the action of counterregulatory hormones and suppresses the ac-tion of insulin, predisposing the client to ketoacidosis and metabolic acidosis. One manifestation of ketoacidosis is a "fruity" odor to the breath. Documentation should occur after all assessments have been completed. The other options are not needed for this problem.
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