Moderate

A nurse realises that a patient received 10 units of rapid-acting insulin instead of the prescribed 4 units. The patient is currently awake and has no symptoms. What should the nurse do first?

Correct answer: A. Check the patient's capillary glucose and assess the patient

  • A. Check the patient's capillary glucose and assess the patient
  • B. Document the error after completing the medication round
  • C. Give a carbohydrate snack without checking the glucose
  • D. Wait for symptoms before informing the prescriber

Explanation

The nurse first assesses the patient's current condition and checks the glucose level because rapid-acting insulin can cause sudden hypoglycaemia. The prescriber and appropriate reporting system are notified after immediate patient assessment begins.

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About Clinical Judgement and Prioritisation

Clinical judgement links assessment findings, nursing knowledge and patient responses to a safe decision. Coverage includes ABCDE assessment, recognising actual or potential instability, prioritising airway, breathing and circulation, using urgency and risk rather than routine order, reassessing after intervention, and distinguishing a nursing priority from a medical diagnosis or a task that can wait.

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