A nurse assesses a client with diabetes mellitus 3 hours after a surgical procedure and notes the client's breath has a "fruity" odor. Which action should the nurse take?
a. Encourage the client to use an incentive spirometer.
b. Increase the client's intravenous fluid flow rate.
c. Consult the provider to test for ketoacidosis.
d. Perform meticulous pulmonary hygiene care.
ANS: C
The stress of surgery increases the action of counterregulatory hormones and suppresses the action 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. Using an incentive spirometer, increasing IV fluids, and performing pulmonary hygiene will not address this client's problem.
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