Registered Nurse (RN) Endocrine Licensure Exam

A patient with diabetes reports symptoms of being sweaty, cold, and clammy with a glucose level of 50. What is the most important nursing intervention?

1. A. Call the doctor

2. B. Keep the patient nothing by mouth

3. C. Recheck the glucose level

4. D. Give the patient ½ cup (4 oz) of fruit juice

The correct answer is: D. Give the patient ½ cup (4 oz) of fruit juice

In this scenario, the patient is exhibiting symptoms of hypoglycemia, which includes feeling sweaty, cold, and clammy, along with a low glucose level of 50 mg/dL. When a patient presents with these signs, it is indicative that their blood sugar is critically low and requires immediate correction to prevent further complications, such as confusion, seizures, or loss of consciousness. Administering a quick source of glucose, such as fruit juice, is crucial in managing hypoglycemia. The ½ cup (4 oz) of fruit juice contains carbohydrates that are rapidly absorbed and will help raise the blood glucose level. This intervention is essential because it addresses the immediate need of the patient and can stabilize their condition. Other interventions such as calling the doctor, keeping the patient NPO (nothing by mouth), or rechecking the glucose level can be part of the overall management but are not prioritized at this moment. Calling the doctor may result in a delay in treatment when immediate action is needed. Keeping the patient NPO would prevent necessary glucose administration that could alleviate hypoglycemia. Rechecking the glucose level could also delay treatment since the current level already indicates a need for intervention. Therefore, providing a fast-acting carbohydrate source is the most important intervention