The mother of the 7-week-old infant reports the baby has had fewer and fewer wet diapers and hasn’t stooled in 3 days despite having a ravenous appetite. The mother reports that the child has been vomiting with increasing force and volume over the past two weeks. The emesis just appears to be partially digested breastmilk and fluid. The infant appears well, but mucous membranes are dry, the child has a low-grade fever, and is tachycardic. Upon palpation of the abdomen, a small, olive-shaped mass is appreciated. A serum electrolyte panel reveals a sodium of 132, potassium of 2.7, chloride of 89, and a glucose of 92. The nurse performs which nursing action first? 

The nurse is checking on the patient who underwent cardiac catheterization via the femoral artery 2 hours after the procedure. The patient appears to be sleeping and the nurse notes that the bruise at the insertion site has increased in size since the last assessment. Which action does the nurse take first?

Which of the following is not indicative that a patient may be in diabetic ketoacidosis?