A nurse is caring for a client who has type 1 diabetes mellitus. The nurse misread the client's morning blood glucose level as 210 mg/dL instead of 120 mg/dL and administered the insulin dose appropriate for a reading over 200 mg/dL before the client's breakfast. Which of the following actions is the nurse's priority?

Choice A rationale Notifying the nurse manager is an appropriate administrative action for reporting a medication error and ensuring workplace safety standards are maintained. However, this is a secondary step in the hierarchy of nursing actions. The priority in an emergency or error situation is always the immediate physical safety and physiological stability of the client. Notifying management does nothing to address the potential life-threatening hypoglycemia the client may be experiencing due to the incorrect insulin dose. Choice B rationale Assessing the client is the first step of the nursing process and is the absolute priority when a medication error is identified. Since the nurse administered an excessive dose of insulin, the client is at high risk for hypoglycemia. The nurse must immediately obtain a current blood glucose reading to determine the severity of the drop. Normal fasting levels are 70 to 100 mg/dL; a reading below 70 mg/dL requires urgent intervention to prevent neurological damage or coma. Choice C rationale Administering carbohydrates is the correct intervention for documented hypoglycemia, but it should follow the assessment of the blood glucose level. Giving 10 grams of carbohydrate might be insufficient if the hypoglycemia is severe, or it might be unnecessary if the blood sugar is still within a safe range. Following the nursing process (ADPIE), assessment must occur before intervention to ensure the treatment provided is appropriate for the client's actual physiological status at that moment. Choice D rationale Completing an incident report is a vital part of the facility's quality improvement and risk management process. It provides a formal record of the error to help prevent future occurrences. However, documentation is never the priority over direct client care. The nurse must first ensure the client is hemodynamically and neurologically stable by checking their blood sugar and treating any hypoglycemia before spending time on the administrative task of filling out an incident or occurrence report.