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Question

Difficulty: EasyPhysiological Adaptation

A nurse is caring for an alert and oriented client with diabetes mellitus who suddenly reports sweating, palpitations, and feeling hungry. Arrange the following nursing actions in the correct order to manage this acute situation.

  1. 1Assess the client's capillary blood glucose level.
  2. 2Administer 15 grams of a fast-acting simple carbohydrate.
  3. 3Reassess the blood glucose level 15 minutes after treatment.
  4. 4Provide a small snack containing a complex carbohydrate and a protein.

Answer

The correct sequence is to first assess the blood glucose, then administer 15 grams of a fast-acting carbohydrate, reassess the blood glucose in 15 minutes, and finally provide a snack with complex carbohydrates and protein.
The correct sequence follows the standard protocol for managing acute hypoglycemia in a conscious client. The nurse first assesses the blood glucose to confirm the condition. Next, 15 grams of a fast-acting carbohydrate is given for rapid absorption. After 15 minutes, the nurse reassesses to evaluate the intervention's effectiveness. Finally, once the glucose level is stable, a complex carbohydrate and protein snack is provided to prevent a secondary hypoglycemic event.

Step-by-Step Solution

1
Confirm the client's condition.
The capillary blood glucose level is assessed to verify hypoglycemia.
Assessment must precede intervention to ensure the correct protocol is followed.
2
Provide rapid treatment.
15 grams of a fast-acting simple carbohydrate is administered.
A simple carbohydrate quickly absorbs into the bloodstream to rapidly raise the blood glucose level.
3
Evaluate the treatment's effectiveness.
The blood glucose level is reassessed 15 minutes after the fast-acting carbohydrate is given.
Monitoring is required to determine if the blood glucose is rising to a safe level or if the initial treatment needs to be repeated.
4
Sustain the blood glucose level.
A snack containing a complex carbohydrate and protein is provided.
Complex carbohydrates and proteins take longer to digest, which helps maintain the blood glucose level and prevents another sudden drop.

Key Concept

The 15/15 Rule for Acute Hypoglycemia Management
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Topics

Physiological Adaptation

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