A client with diabetes mellitus type 1 is found unresponsive in the clinical setting. Which nursing action is a priority?
1. Call a code.
2. Treat the client for hypoglycemia.
3. Call the physician STAT.
4. Assess the client's vital signs.
2
Rationale 1: Assessment for ABCs should precede calling a code; there is no information that the client is not breathing.
Rationale 2: When a client with diabetes mellitus type 1 is found unresponsive, the nurse should focus on and treat for hypoglycemia, as this is more likely than hyperglycemia.
Rationale 3: This is an emergency situation where the nurse must act before calling the physician.
Rationale 4: Vital signs should be taken after the client is treated for hypoglycemia.
Global Rationale: When a client with diabetes mellitus type 1 is found unresponsive, the nurse should focus on and treat for hypoglycemia, as this is more likely than hyperglycemia. Assessment for ABCs should precede calling a code; there is no information that the client is not breathing. This is an emergency situation where the nurse must act before calling the physician. Vital signs should be taken after the client is treated for hypoglycemia.
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