# Stage 5 — Take action. The day-shift charge RN receives handoff while Mr. P remains at risk for recurrent hypoglycemia. Place the five actions in the safest sequence for the initial response; urgent steps may overlap when additional team members are available. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=372849&lang=en > language: en > subject: Assignment/Delegation/Supervision > category: MOC ## Question Stage 5 — Take action. The day-shift charge RN receives handoff while Mr. P remains at risk for recurrent hypoglycemia. Place the five actions in the safest sequence for the initial response; urgent steps may overlap when additional team members are available. Notify safety or risk staff, preserve relevant paper and electronic records, and arrange immediate confidential support for the involved nurse without pre-classifying behavior. Use the trained disclosure process for timely factual communication with the client and family, and document the patient's condition, treatment, response, notifications, and clinically relevant communication in the health record. Complete the confidential safety-event report promptly with factual information and ensure the event enters the follow-up system-analysis process. Notify the responsible clinician and pharmacist, hold further insulin pending review, and obtain orders for continuing glucose, neurologic, dextrose, and potassium management. Assess the client, activate or continue the hypoglycemia protocol, treat as ordered, and repeat point-of-care glucose every 15 minutes until above 70 mg/dL and stable. ## Explanation Safest sequence: 2 → 3 → 4 → 5 → 1 First, assess, treat, and repeat point-of-care testing. Next, engage the clinician and pharmacist to control continuing medication and metabolic risk. Then notify safety staff, preserve records, and support the nurse so evidence and people are protected. Conduct timely factual disclosure and clinical documentation, followed by a complete confidential safety report and follow-up handoff. Team members may perform urgent elements concurrently; the sequence expresses priority, not permission to delay reporting or communication. ## In-depth explanation 1 — Stabilize and detect recurrence The first normal glucose does not end the emergency. Continue protocol-based treatment and point-of-care testing until stable, then monitor according to the excess-insulin risk. 2 — Control ongoing orders The clinician and pharmacist help hold or revise insulin, direct dextrose support, and monitor potassium and neurologic status. 3 — Preserve evidence and support people Safety or risk notification, record preservation, and confidential peer support begin early. None requires a premature conclusion about behavior or final event classification. 4 and 5 — Communicate, document, and report Use trained, factual disclosure and record clinical care in the health record. Complete the separate safety report promptly and ensure ownership of the system follow-up. In a real team response, these workstreams can overlap. ## Clinical scenario Scenario (Stage 5 — Take action) The client has received initial dextrose but the excess regular insulin remains active, the daughter needs an explanation, and safety staff are available. Clinical judgment target Sequence clinical stabilization, medication control, evidence preservation, communication, documentation, and confidential reporting. ## Key concepts - **Parallel workstreams** — Patient stabilization, clinician coordination, communication, documentation, reporting, and staff support may occur simultaneously when personnel are available even though a test item asks for priority order. - **Clinical documentation** — A factual record of patient assessment, treatment, response, notifications, and relevant communication without blame, speculation, or a copied confidential incident report. - **Safety-event reporting** — Prompt confidential reporting that routes an event into organizational follow-up and system learning without replacing immediate patient care or health-record documentation. ## Related questions - [A 67-year-old client with chronic obstructive pulmonary disease attends a routine primary …](https://mymerci.kr/pages/nclex_q.php?qn_id=360522&lang=en) - [A registered nurse on a medical-surgical unit is delegating tasks at the start of shift. 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