Examkin

Question

Difficulty: MediumPhysiological Adaptation

A practical nurse (PN) is caring for an alert and conscious client with type 1 diabetes mellitus who suddenly reports feeling shaky, dizzy, and diaphoretic. The PN performs a capillary blood glucose test, which reads 48 mg/dL (2.7 mmol/L). In which order should the PN perform the following actions? (Arrange the actions from first to last.)

  1. 1Give the client 15 grams of a fast-acting simple carbohydrate.
  2. 2Recheck the capillary blood glucose level after 15 minutes.
  3. 3Repeat the simple carbohydrate dose if the blood glucose is still below 70 mg/dL (3.9 mmol/L).
  4. 4Provide a snack containing a complex carbohydrate and a protein.
  5. 5Document the hypoglycemic episode, interventions, and the client's response.

Answer

The correct order is to administer a simple carbohydrate, wait 15 minutes to recheck the glucose, repeat the simple carbohydrate if still low, provide a complex snack once stable, and finally document the event.
The 'Rule of 15' is the standard evidence-based protocol for managing hypoglycemia in a conscious client. The nurse first provides 15 grams of a fast-acting simple carbohydrate to rapidly raise the blood sugar. Waiting 15 minutes allows the sugar to absorb before rechecking the blood glucose. If it remains below 70 mg/dL, the 15-gram carbohydrate dose is repeated. Once the blood glucose is above 70 mg/dL, a complex carbohydrate and protein snack is given to sustain the blood sugar levels. Finally, the nurse documents the entire event.

Step-by-Step Solution

1
Administer 15 grams of a fast-acting simple carbohydrate.
The client receives an immediate source of glucose to rapidly treat the acute hypoglycemia.
Because the client is conscious and can swallow, a fast-acting oral carbohydrate (like 4 ounces of juice) is the fastest and safest way to increase blood sugar and prevent progression to unconsciousness or seizures.
2
Recheck the capillary blood glucose level after 15 minutes.
The PN evaluates the client's response to the initial intervention.
It takes approximately 15 minutes for the simple carbohydrate to enter the bloodstream and effectively raise the blood glucose level.
3
Repeat the simple carbohydrate dose if the blood glucose is still below 70 mg/dL (3.9 mmol/L).
The client receives additional glucose if the first dose was insufficient.
If the blood glucose remains below the safe threshold of 70 mg/dL, the hypoglycemia has not resolved, and another immediate rapid intervention is necessary.
4
Provide a snack containing a complex carbohydrate and a protein.
The client's blood glucose is stabilized over a longer period.
Simple carbohydrates are metabolized quickly. Providing a complex carbohydrate and protein ensures a steady, prolonged release of glucose to prevent a recurrent drop in blood sugar.
5
Document the hypoglycemic episode, interventions, and the client's response.
The medical record is updated with accurate clinical data.
Accurate documentation is legally and clinically required, but it is the lowest priority and must be done only after the client is safe and stable.

Key Concept

Management of Acute Hypoglycemia (Rule of 15)
Rate this question

Topics

Physiological Adaptation

More questions from this topic