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Difficulty: MediumReduction of Risk Potential

A practical nurse (PN) is caring for a conscious client with diabetes mellitus who suddenly reports feeling shaky and appears diaphoretic. Arrange the following nursing actions in the correct priority sequence to manage this situation and reduce the risk of severe complications. All options must be used.

  1. 1Obtain a capillary blood glucose reading.
  2. 2Administer 4 ounces (120 mL) of a fast-acting carbohydrate, such as apple juice.
  3. 3Wait 15 minutes and reassess the capillary blood glucose level.
  4. 4Provide a complex carbohydrate and protein snack.
  5. 5Document the client's symptoms, interventions, and blood glucose results.

Answer

The correct sequence is to first check the blood glucose, administer a fast-acting carbohydrate, recheck in 15 minutes, provide a stabilizing snack, and finally document the event.
The correct sequence follows the standard 'Rule of 15' for hypoglycemia management combined with the nursing process. Assessment (checking blood glucose) must precede intervention. The immediate intervention is a simple carbohydrate to rapidly raise blood sugar. Evaluation (rechecking in 15 minutes) determines if further acute treatment is needed. Once stable, a complex snack prevents recurrence, and final documentation records the resolved incident.

Step-by-Step Solution

1
Obtain a capillary blood glucose reading.
Confirms if the client's symptoms are due to hypoglycemia.
Assessment is always the first step in the nursing process to ensure interventions are appropriate.
2
Administer 4 ounces (120 mL) of a fast-acting carbohydrate.
Rapidly increases the client's blood glucose level.
This follows the 'Rule of 15' for treating symptomatic hypoglycemia in a conscious client.
3
Wait 15 minutes and reassess the capillary blood glucose level.
Evaluates the client's response to the simple carbohydrate.
It takes approximately 15 minutes for the simple carbohydrate to absorb and affect the capillary glucose level. If it remains low, the treatment must be repeated.
4
Provide a complex carbohydrate and protein snack.
Maintains the blood glucose level over a longer period.
Simple carbohydrates cause a rapid spike and subsequent drop; complex carbohydrates and protein stabilize the level until the next meal.
5
Document the client's symptoms, interventions, and blood glucose results.
Provides an accurate legal and medical record of the event.
Documentation occurs after patient care is completed and the client is stable.

Key Concept

Management of Hypoglycemia (Rule of 15)
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Topics

Reduction of Risk Potential

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