A nurse assesses a client with diabetes mellitus and notes the client only responds to a sternal rub by moaning, has capillary blood glucose of 33 g/dL, and has an intravenous line that is infiltrated with 0.45% normal saline
Which action should the nurse take first?
a.
Administer 1 mg of intramuscular glucagon.
b.
Encourage the client to drink orange juice.
c.
Insert a new intravenous access line.
d.
Administer 25 mL dextrose 50% (D50) IV push.
ANS: A
The client's blood glucose level is dangerously low. The nurse needs to administer glucagon IM immediately to increase the client's blood glucose level. The nurse should insert a new IV after administering the glucagon and can use the new IV site for future doses of D50 if the client's blood glucose level does not rise. Once the client is awake, orange juice may be administered orally along with a form of protein such as a peanut butter.
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