A client with diabetes is unconscious, has a blood glucose of 31 mg/dL, and has no intravenous access. Which action should the nurse take?
1Place the client upright and give orange juice by mouth while another nurse obtains intravenous access.
2Give prescribed glucagon, turn the client to the side, call for emergency help, and monitor the response.✓ Correct answer
3Administer rapid-acting insulin subcutaneously and recheck the blood glucose after 15 minutes.
4Wait until intravenous access is established before treating because intramuscular medication acts too slowly.
Explanation
An unconscious client cannot safely swallow. When severe hypoglycemia occurs and intravenous access is unavailable, prescribed glucagon is administered promptly. The client is turned to the side because vomiting can occur, emergency help is activated, and glucose and airway status are monitored. Once awake and able to swallow, the client receives carbohydrate according to the treatment plan.
Clinical reasoning Severe hypoglycemia can cause seizures, brain injury, or death. Oral carbohydrate creates an aspiration risk in an unconscious client, and insulin would worsen the emergency.
Decision rule If the client cannot swallow and intravenous glucose is not immediately available, give prescribed glucagon, position laterally, call for emergency support, and continue glucose and airway monitoring.