NCLEX · Reduction of Risk Potential

A diabetic client's morning fasting blood glucose is 52 mg/dL and the client is alert and able to swallow. What is the appropriate nursing intervention?

Correct answer

Give 15 grams of fast-acting carbohydrate (4 oz juice, glucose tablets, or regular soda), wait 15 minutes, and recheck blood glucose — the '15-15 rule' for treating conscious hypoglycemia

  1. A Call a code
  2. B Withhold all food until the provider rounds
  3. C Give 15 grams of fast-acting carbohydrate (4 oz juice, glucose tablets, or regular soda), wait 15 minutes, and recheck blood glucose — the '15-15 rule' for treating conscious hypoglycemia
  4. D Administer the scheduled insulin dose

Why this is the answer

HYPOGLYCEMIA TREATMENT — THE 15-15 RULE: For a CONSCIOUS client able to swallow with blood glucose < 70 mg/dL: GIVE 15g fast-acting carbohydrate: 4 oz (1/2 cup) fruit juice or regular soda; 3-4 glucose tablets; 1 tablespoon honey or sugar; 8 oz milk; WAIT 15 minutes; RECHECK blood glucose; REPEAT if still < 70; Once normalized, provide a complex carb + protein snack if next meal is > 1 hour away (prevents rebound hypoglycemia); UNCONSCIOUS or unable to swallow: Do NOT give oral anything (aspiration risk); give IM/SubQ glucagon or IV dextrose (D50); NEVER give insulin to a hypoglycemic patient — insulin lowers glucose further; HOLD scheduled insulin and notify provider when glucose is low;

Hypoglycemia signs: shakiness, sweating, tachycardia, hunger, confusion, irritability; severe: seizures, loss of consciousness; LPN role: recognize and treat per protocol, recheck, notify RN.

Source: NCLEX-PN Physiological — Reduction of Risk, Hypoglycemia 15-15 Rule

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About this topic: Reduction of Risk Potential

Reduction of risk potential questions cover vital signs, lab values, diagnostic tests, and the complications to anticipate after procedures and surgery — recognising early signs and knowing what to report. This is one of 16 PN: Physiological Integrity questions on reduction of risk potential, each with a full explanation on a single study page.

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