medium · NCLEX-RN Reduction of Risk Potential

A client's point-of-care (POC) capillary glucose result is 'High' (above 600 mg/dL), but the client is alert, oriented, and denies any symptoms of hyperglycemia.

What is the nurse's safest first action?

  1. Administer the ordered sliding-scale insulin based on the 'High' reading immediately.
  2. Wait 2 hours and repeat the capillary check to see if the value remains high, for this client.
  3. Ask the client what they recently ate to explain the high reading.
  4. Confirm the result with a stat venous laboratory sample and check the device quality control.

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