A practical nurse (PN) enters the room of a client with type 1 diabetes mellitus. The client is pale, diaphoretic, and states, 'I feel very shaky.' The PN checks the capillary blood glucose, which is 42 mg/dL (2.3 mmol/L). The client is conscious and able to swallow. In what order should the PN perform the following actions? (Arrange the items in the correct sequence from first to last.)
- 1Administer 15 grams of a fast-acting simple carbohydrate, such as 4 ounces of fruit juice.
- 2Wait 15 minutes to allow the simple carbohydrate to absorb.
- 3Reassess the client's capillary blood glucose level.
- 4Provide a snack containing a complex carbohydrate and protein, such as cheese and crackers.
- 5Document the hypoglycemic event, interventions, and client's response in the medical record.
Answer
The correct sequence is to first treat the hypoglycemia with a fast-acting carbohydrate, wait 15 minutes, recheck the blood glucose, provide a stabilizing snack, and finally document the event.
The 'Rule of 15' is the standard evidence-based protocol for managing hypoglycemia in a conscious client. It dictates administering 15 grams of fast-acting carbohydrates, waiting 15 minutes, and rechecking the blood glucose. Once the glucose is above 70 mg/dL, a complex carbohydrate and protein snack is given to maintain stability, followed by accurate documentation of the entire event.
Step-by-Step Solution
Key Concept
Hypoglycemia Management (Rule of 15)