Question

The nurse is monitoring the glucose q4h of an adult woman admitted with DKA. Two hours after receiving 10 units of regular insulin for glucose of 255, the client is perspiring and complaining of shakiness. What intervention should the nurse implement?

Answer 1

If a client experiences perspiration and shakiness after receiving insulin, it indicates low blood glucose levels. The nurse should administer a fast-acting source of glucose and closely monitor the client's blood glucose levels.

Step-by-step explanation:

If a client is perspiring and complaining of shakiness two hours after receiving 10 units of regular insulin for a glucose level of 255, it indicates that the client's blood glucose level has dropped too low, causing hypoglycemia. In this situation, immediate intervention is necessary to raise the blood glucose level to a safe range. The nurse should implement the following intervention:

1. Administer a fast-acting source of glucose, such as orange juice or a glucose gel, to the client to quickly raise their blood glucose level.
2. Monitor the client's blood glucose level closely after administering the glucose, and repeat the intervention if necessary, ensuring their blood glucose level stays within a target range.
3. Document the client's symptoms, the intervention implemented, and the client's response to the intervention in their medical record.