An adult client with a history of type 2 diabetes mellitus and hypertension is assigned to a practical nurse. During the morning assessment, the client is awake and reports feeling slightly shaky. The vital signs are a blood pressure of 142/88 mm Hg, an apical heart rate of 54 beats/minute, and a capillary blood glucose level of 64 mg/dL (3.5 mmol/L). The medication administration record includes scheduled morning doses of oral glipizide, subcutaneous regular insulin, and oral atenolol. Which of the following actions should the practical nurse take? Select all that apply.
- Withhold the scheduled doses of oral glipizide and subcutaneous regular insulin.Answer
- Provide the client with 15 grams of a fast-acting oral carbohydrate.Answer
- Withhold the scheduled dose of oral atenolol and report the apical heart rate.Answer
- DAdminister the oral atenolol to manage the client's current blood pressure.
- EGive the subcutaneous regular insulin and hold the oral glipizide until after a meal.
- FDelegate the administration of fruit juice and the follow-up blood glucose check to an unlicensed assistive personnel (UAP).
Answer
The practical nurse should withhold the glipizide and regular insulin, provide a fast-acting carbohydrate to treat the hypoglycemia, and withhold the atenolol due to the client's bradycardia.
The client is experiencing both hypoglycemia (blood glucose 64 mg/dL with shakiness) and bradycardia (heart rate 54 beats/minute). Safe nursing practice requires holding all medications that would exacerbate these conditions. Glipizide and regular insulin must be withheld to prevent further drops in blood glucose, and a fast-acting carbohydrate must be given immediately. Atenolol must be withheld because it is a beta-blocker that will further lower the client's heart rate. The nurse must report these abnormal findings to the healthcare provider or registered nurse.
Step-by-Step Solution
Key Concept
Safe medication administration requires the nurse to verify that current clinical data, such as vital signs and laboratory values, support the safe administration of scheduled medications.