A 74-year-old woman who is a known diabetic is brought to the ED by emergency medical service (EMS) with altered mental status.

A 74-year-old woman who is a known diabetic is brought to the ED by emergency medical service (EMS) with altered mental status. The home health aide states that the patient ran out of her medications 4 days ago. Her BP is 130/85 mm Hg, HR is 110 beats per minute, temperature is 99.8°F, and RR is 18 breaths per minute. On examination, she cannot follow commands but responds to stimuli. Laboratory results reveal white blood cell (WBC) count of 14,000/L, hematocrit 49%, platelets 325/L, sodium 128 mEq/L, potassium 3.0 mEq/L, chloride 95 mEq/L, bicarbonate 22 mEq/L, blood urea nitrogen (BUN) 40 mg/dL, creatinine 1.8 mg/dL, and glucose 850 mg/dL. Urinalysis shows 3+ glucose, 1+ protein, and no blood or ketones. After addressing the ABCs, which of the following is the most appropriate next step in management?

a. Begin fluid resuscitation with a 2-to 3-L bolus of normal saline; then administer 10 units of regular insulin intravenously.

b. Begin fluid resuscitation with a 2-to 3-L bolus of normal saline; then administer 10 units of regular insulin intravenously and begin phenytoin for seizure prophylaxis.

c. Administer 10 units of regular insulin intravenously; then begin fluid resuscitation with a 2-to 3-L bolus of normal saline.

d. Order a computed tomographic (CT) scan of the brain; if negative for acute stroke, begin fluid resuscitation with a 2-to 3-L bolus of normal saline.

e. Arrange for urgent hemodialysis

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