Question

A nurse is caring for a client diagnosed with diabetes. The nurse notes that the client has a mild tremor, slight diaphoresis and is fully oriented. Which of the following nursing actions should have the highest priority?

1) Call the lab for a stat glucose level
2) Assess the client's blood glucose level
3) Give the client 4 ounces of orange juice
4) Administer 50

Answer 1

The highest priority nursing action for a diabetic client showing symptoms of hypoglycemia, such as a mild tremor and diaphoresis, is to assess the client's blood glucose level. Following confirmation, the nurse should provide a quick source of sugar.

Step-by-step explanation:

A nurse caring for a client with diabetes who exhibits a mild tremor, slight diaphoresis, and full orientation is likely experiencing symptoms of hypoglycemia, which is characterized by low blood glucose levels. The highest priority nursing action in this situation would be to assess the client's blood glucose level to confirm the hypoglycemic state. If the blood glucose assessment confirms hypoglycemia, the nurse should then provide a quick source of sugar, such as 4 ounces of orange juice, to rapidly elevate the client's blood glucose level.

Diabetes mellitus is a condition where the body either does not produce enough insulin, or does not properly respond to insulin. Hypoglycemia can occur due to an imbalance in diabetes management, such as excessive insulin dosage or insufficient food intake. Prompt recognition and treatment are essential to prevent further complications such as convulsions, fainting, coma, or even death.