A nurse is caring for an alert and oriented client with diabetes mellitus who reports feeling shaky and sweaty. The client's capillary blood glucose level is 55 mg/dL. Arrange the following nursing interventions in the correct order of priority.
- 1Administer 15 grams of a fast-acting simple carbohydrate.
- 2Wait 15 minutes to allow the carbohydrate to absorb.
- 3Reassess the client's capillary blood glucose level.
- 4Provide a snack containing complex carbohydrates and protein.
Answer
The correct sequence follows the 'Rule of 15' for managing hypoglycemia: administer 15 grams of simple carbohydrates, wait 15 minutes, reassess blood glucose, and finally provide a sustaining snack.
The 'Rule of 15' is the standard protocol for managing mild to moderate hypoglycemia in a conscious client. It begins with the immediate administration of 15 grams of a fast-acting carbohydrate to rapidly raise blood glucose. The nurse then waits 15 minutes to allow for absorption before reassessing the blood glucose level. If the level remains below 70 mg/dL, the process is repeated. Once the level normalizes (above 70 mg/dL), a complex carbohydrate and protein snack is provided to maintain blood glucose stability.
Step-by-Step Solution
Key Concept
Hypoglycemia Management (Rule of 15)