After the 0700 report, the day shift nurse notices that a patient has a 0730 dose of insulin due and goes to the automated dispensing machine to retrieve the insulin. The nurse sees that the night shift nurse had removed the 0730 dose of insulin, but the medication administration record has not been signed by the nurse. The patient is confused and says she thinks the night nurse gave her the insulin. The patient's blood glucose level is 142 mg/dL. What will the day shift nurse do?

Choice A rationale Giving the insulin is not safe because there is a possibility the patient has already received it, even though the record is not signed. Administering a second dose of insulin could lead to hypoglycemia, a life-threatening condition where the blood glucose level drops dangerously low, causing symptoms like confusion, seizures, and unconsciousness. Choice B rationale Holding the insulin is the initial safe action, but simply holding it doesn't resolve the issue and leaves the patient's care plan incomplete. The primary concern is the potential for a double dose and the lack of proper documentation. The problem requires a more formal and structured response than simply holding the medication and moving on. Choice C rationale Contacting the night nurse is an option, but it is not the most immediate or appropriate action. The night nurse may be asleep or unreachable. The nurse on duty is responsible for the patient's safety and should follow proper chain of command and reporting protocols to resolve the issue promptly and ensure patient safety. Choice D rationale This situation involves a medication discrepancy, a potential medication error, and a significant safety risk to the patient. Reporting it to the nursing supervisor is the correct and necessary action. The supervisor can initiate a formal investigation, ensure the patient is safe, and address the documentation issue to prevent future errors.