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