A nurse assesses a client with diabetes mellitus and notes the client only responds to a sternal rub by moaning, has a capillary blood glucose of 33 g/dL, and has an intravenous line that is infiltrated with 0.45% normal saline. Which action should the nurse take first?

Choice A rationale: The client's altered level of consciousness (responding only to a sternal rub) and severely low capillary blood glucose of 33 g/dL (normal range 70-110 mg/dL) indicate severe hypoglycemia. The IV line is infiltrated, making IV dextrose administration impossible. In this situation, intramuscular glucagon is the most rapid and effective intervention. It mobilizes hepatic glycogen stores to increase blood glucose levels, a critical and immediate action to prevent further neurological damage or death. Choice B rationale: The client's decreased level of consciousness makes it unsafe to administer oral fluids like orange juice due to the high risk of aspiration. The client cannot swallow safely. This intervention would be appropriate for a client who is conscious and able to swallow, but not for one who only responds to a sternal rub. Choice C rationale: While a new intravenous line is necessary for future care and potential IV dextrose administration, this is not the first action. The client's severe hypoglycemia requires an immediate increase in blood glucose. Inserting a new line takes time, and the delay could be fatal. Intramuscular glucagon is the fastest way to reverse the immediate threat. Choice D rationale: Elevating the head of the bed may be a prudent action to maintain a patent airway and reduce the risk of aspiration. However, it is not the first priority. The client's life is at immediate risk from the profound hypoglycemia. The priority is to raise the blood glucose level, which intramuscular glucagon can accomplish rapidly.