A nurse is preparing a 62-year-old client with type 2 diabetes mellitus for a scheduled total hip arthroplasty. The client has been NPO since midnight and received their prescribed evening dose of long-acting insulin. During the preoperative assessment, the blood glucose reading is 180 mg/dL. The client appears highly anxious and asks, "Will my surgery be canceled because my sugar is high?" What is the most appropriate nursing intervention?

Preoperative blood glucose management is critical for diabetic clients undergoing surgery. A glucose level of 180 mg/dL requires intervention before surgery to optimize outcomes and reduce complications.

Core Nursing Explanation Key Concept Analysis: This question tests the nurse's knowledge of preoperative glycemic management for a patient with Diabetes Mellitus (DM). The core principle is that hyperglycemia in the perioperative period increases the risk of surgical site infections, poor wound healing, and metabolic complications. The patient is NPO (Nothing by mouth) and has received long-acting insulin, creating a dynamic situation where both hyperglycemia from stress/anxiety and the risk of hypoglycemia from fasting must be managed. The nurse's role is to intervene within their scope, following established protocols, and communicate with the healthcare team.

Answer Rationale: Key Point! The correct action is to Administer rapid-acting insulin as per sliding scale protocol and notify the anesthesiologist. A blood glucose of 180 mg/dL is elevated and requires correction. Most institutions have a preoperative Sliding scale insulin protocol for such situations. Administering the insulin addresses the immediate hyperglycemia. Notifying the anesthesiologist is crucial because they manage the patient's physiology during surgery and need to be aware of the glucose level and any insulin given to monitor for intraoperative hypoglycemia or hyperglycemia. This intervention is proactive, evidence-based, and collaborative.

Distractor Analysis:
Watch out for confusion! Option ②, "Cancel the surgery," is an extreme and inappropriate action for a moderately elevated glucose level. Surgery is not typically canceled for this value; instead, it's a signal for intervention. The nurse does not have the authority to cancel surgery.
Option ③, "Proceed with surgery as planned," is incorrect because it ignores the elevated glucose. While target ranges may be slightly relaxed perioperatively (e.g., 140-180 mg/dL is often an acceptable intraoperative range), 180 mg/dL at the preoperative stage should still be addressed to prevent further rise from surgical stress.
Option ④, "Give orange juice," is dangerous. The patient is NPO for surgery to prevent aspiration. Administering oral carbohydrates would violate NPO orders and could cause aspiration pneumonia. Furthermore, giving sugar for a high blood glucose level is the opposite of the required treatment.

Related Concepts: Perioperative management of diabetes involves balancing insulin needs while the patient is fasting. Long-acting insulin (e.g., glargine, detemir) is often continued at a reduced dose, but rapid-acting insulin is used for correction. The stress of surgery and anxiety can cause counter-regulatory hormone release (cortisol, epinephrine), leading to elevated blood glucose. The nurse must also provide emotional support and education to alleviate the patient's anxiety.

Nursing Clinical Practice Guide Clinical Scenario: You are the preoperative nurse for Mr. Johnson, a 62-year-old with Type 2 DM scheduled for a total hip replacement. He has been NPO since midnight, took his usual dose of insulin glargine last night, and now his fingerstick glucose is 180 mg/dL. He is visibly anxious, tapping his fingers and asking repeated questions about surgery cancellation.

Nursing Intervention Strategy: 1. Assessment: Confirm the glucose reading with a second check if unsure. Assess for other signs of hyperglycemia (dry mouth, frequent urination if not NPO) or impending hypoglycemia (anxiety can mimic hypoglycemia symptoms). Review the patient's medication list and the specific preoperative orders for insulin management. 2. Intervention: * Check the physician's orders or unit protocol for "Preoperative Sliding Scale Insulin." Calculate and administer the correct dose of rapid-acting insulin (e.g., insulin aspart, lispro) subcutaneously. * Immediately after administration, notify the anesthesia team or the anesthesiologist directly. Report: "Patient Mr. Johnson, going for total hip arthroplasty, preoperative glucose 180, received X units of insulin aspart at [time]." * Reassure the patient. Explain that this is a common situation, the team is managing it, and his surgery will proceed as planned. "Mr. Johnson, your sugar is a bit high, which can happen when you're anxious and fasting. We've given a small dose of insulin to correct it, and I've let the anesthesia doctor know. This is part of our standard procedure to keep you safe during surgery." 3. Monitoring & Evaluation: Document the glucose reading, insulin administered, site of injection, and notification of the anesthesia provider. Continue to monitor the patient's status. The anesthesia team will frequently check blood glucose during and after surgery.

Patient Safety and Precautions: The cardinal rule is NPO means NPO. Do not give any oral fluids or medications unless specifically ordered and safe to do so (e.g., with a small sip of water). Double-check insulin doses with another nurse if required by policy. Be aware of the peak time of the rapid-acting insulin (typically 1-2 hours) so the anesthesia team knows when to expect the maximal effect.

Nursing Procedure & Medication Flow Administering Preoperative Sliding Scale Insulin: 1. Perform hand hygiene and don gloves. 2. Verify patient identity using two identifiers. 3. Perform fingerstick blood glucose check, ensuring proper technique for accurate reading. 4. Consult the sliding scale order (e.g., 150-200 mg/dL = 2 units; 201-250 mg/dL = 4 units, etc.). 5. Withdraw the correct dose of rapid-acting insulin into an insulin syringe. Always use an insulin syringe for U-100 insulin. 6. Select an appropriate subcutaneous site (abdomen, thigh). Cleanse with alcohol and allow to dry. 7. Administer the injection subcutaneously. 8. Do not massage the site. 9. Document immediately: Time, glucose value, insulin type/dose/route/site. 10. Communicate the action to the anesthesia provider and the receiving nurse in the OR holding area. A Word from Your Senior Nurse "In the fast-paced preoperative area, it's easy to get task-focused. But remember, your patient is scared and vulnerable. Mr. Johnson's question about surgery cancellation comes from fear. While you're expertly managing his glucose, don't forget to manage his anxiety. A calm, confident explanation of what you're doing and why can be as therapeutic as the insulin. You are the bridge between the patient and the complex surgical system. Mastering these dual roles—technical expert and compassionate advocate—is what makes an extraordinary nurse. On the NCLEX, they test your knowledge of the insulin; in practice, you'll be tested on how you deliver that care with empathy."