A patient with hyperglycemia on a med-surg unit shows glucose >300 mg/dL with mild dehydration. Which nurse actions are appropriate?

• A. Monitor glucose regularly.
• B. Ensure IV fluids per protocol.
• C. Assess for ketones and for DKA/HHS.
• D. Escalate per protocol after completing the above actions.

Answer: (D)

When glucose is high and dehydration is present, the nurse’s first responsibility is to stabilize the patient and gather information that guides further treatment. Start with the foundational steps: monitor the blood glucose to track trends, administer IV fluids per protocol to address dehydration and support perfusion, and assess for ketones and signs of DKA or HHS to determine the severity and appropriate mode of therapy.

Escalation per protocol after completing those actions is the best path because it ensures the patient has received immediate stabilization and a complete assessment before moving to more intensive interventions. If hyperglycemia persists or if ketones are present, the care plan can be adjusted quickly by notifying the physician and initiating the appropriate protocol, such as insulin therapy and electrolyte management, as indicated.

Why intermediate steps alone aren’t enough: simply monitoring without fluids won’t correct dehydration; fluids alone won’t identify whether a dangerous hyperglycemic crisis is developing; ketone assessment is essential to distinguish DKA/HHS from milder hyperglycemia and to tailor treatment. By performing the initial stabilization and assessment first, you put yourself in the best position to decide the next, correct action promptly.