NCLEX-RNReduction of Risk PotentialEasy
A nurse is caring for a client with type 1 diabetes who received regular insulin 45 minutes ago before lunch. The client's lunch tray has not yet arrived. The client becomes diaphoretic, tremulous, and reports feeling shaky. A fingerstick glucose reads 58 mg/dL. Which action should the nurse take first?
- ARecheck the blood glucose in 15 minutes
- BGive the client 4 ounces of orange juice
- CNotify the healthcare provider immediately
- DAdminister glucagon intramuscularly
Show answer & explanationAnswer & explanation
Correct answer: B. Give the client 4 ounces of orange juice
A blood glucose of 58 mg/dL with symptoms of mild-to-moderate hypoglycemia in a conscious, alert client is treated with 15 g of fast-acting oral carbohydrate, such as 4 ounces of juice, following the 'rule of 15.' Glucose should then be rechecked in 15 minutes.
Why the other options are wrong
- A. Rechecking glucose is appropriate but only after treatment has been given, not before.
- C. Provider notification is not urgent for a conscious client with mild hypoglycemia treatable at the bedside.
- D. Glucagon is reserved for unconscious clients or those unable to swallow safely.
Rule of 15 (Hypoglycemia)
For a conscious client with blood glucose under 70 mg/dL, give 15 g of fast-acting carbohydrate and recheck glucose in 15 minutes; repeat if still low.
- Fast carbs: 4 oz juice, glucose tabs, hard candy
- Glucagon IM/IN reserved for unconscious/unable to swallow
- Recheck glucose 15 minutes after treatment
- Follow with complex carb/protein snack once stable
Memory trick: '15-15 rule: 15 grams, wait 15 minutes.'