A practical nurse (PN) is evaluating an alert and oriented client with diabetes mellitus who reports sudden shakiness, weakness, and diaphoresis. The client's capillary blood glucose level is 54 mg/dL (3.0 mmol/L). Arrange the following nursing actions in the correct chronological order of implementation.
- 1Provide 4 ounces (120 mL) of apple juice to the client.
- 2Wait 15 minutes.
- 3Recheck the client's capillary blood glucose level.
- 4Offer a small snack of peanut butter and crackers.
Cevap
The correct sequence is to first administer a fast-acting carbohydrate (apple juice), wait 15 minutes, recheck the capillary blood glucose, and finally provide a complex carbohydrate and protein snack.
For a conscious client experiencing acute hypoglycemia (blood glucose less than 70 mg/dL), the standard evidence-based protocol is the 'Rule of 15'. The nurse must first administer 15 grams of a fast-acting, easily digestible carbohydrate (such as 4 ounces of juice) to quickly raise the blood sugar. The nurse then waits exactly 15 minutes to allow for absorption before rechecking the blood glucose level to see if it has risen above 70 mg/dL. Once the acute hypoglycemia is resolved, a complex carbohydrate and protein snack (like peanut butter and crackers) is provided to maintain the blood glucose level and prevent a subsequent drop.
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Rule of 15 for Hypoglycemia Management