# A 78-year-old client with type 2 diabetes lives alone and takes glipizide 10 mg orally before breakfast. The home health nurse arrives at 1100 to find the client confused, diaphoretic, and tremulous. The client says they took the morning glipizide but did not eat breakfast because of nausea. Bedside blood glucose is 42 mg/dL. Which sequence of actions is most appropriate?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=375053&lang=en  
> language: en  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PA

## Question

A 78-year-old client with type 2 diabetes lives alone and takes glipizide 10 mg orally before breakfast. The home health nurse arrives at 1100 to find the client confused, diaphoretic, and tremulous. The client says they took the morning glipizide but did not eat breakfast because of nausea. Bedside blood glucose is 42 mg/dL. Which sequence of actions is most appropriate?

## Option

1. Administer 4 oz of orange juice orally (if the client cannot swallow, call EMS for glucagon), recheck blood glucose in 15 minutes, and if it exceeds 70 mg/dL, hold the next scheduled dose of glipizide and allow the client to resume normal activities; document the event and inform the provider that no further medical intervention is needed because the hypoglycemia was caused by a missed meal.
2. Treat hypoglycemia per protocol (oral 15 g rapid carb if able to swallow, or call EMS / give IM glucagon if unable), recheck blood glucose in 15 minutes, plan continued observation because sulfonylurea-induced hypoglycemia often recurs and may require IV dextrose infusion and inpatient monitoring; identify cause (missed meal) and adjust plan with the provider. **✔ Correct answer**
3. Give 16 oz of orange juice with two tablespoons of sugar added (if awake enough to drink), recheck blood glucose in 15 minutes; once above 70 mg/dL, provide a carbohydrate-containing meal and skip the next dose of glipizide, with no need for hospital monitoring since the episode was triggered by a missed breakfast which can be prevented with education.
4. Because the client is confused and may aspirate, do not give anything by mouth; call EMS to transport the client to the hospital for intravenous dextrose administration and discharge once normoglycemic, as sulfonylurea-induced hypoglycemia is typically brief and does not require prolonged monitoring after correction.

**Correct answer: 2**

## Explanation

Sulfonylurea-induced hypoglycemia — extended observation
Sulfonylureas (glipizide, glyburide, glimepiride) stimulate pancreatic beta cells to secrete insulin and can cause prolonged, recurrent hypoglycemia, especially in:
• Elderly (impaired counter-regulation, slower drug clearance).
• Missed meal.
• Renal/hepatic impairment.
• Drug interactions (sulfa, beta-blockers, alcohol).

Glyburide has the longest half-life and is generally avoided in the elderly per Beers list.

Management of severe sulfonylurea hypoglycemia:
(1) 15-15 rule if alert and swallows safely: 15 g rapid carb, recheck in 15 min, repeat if needed.
(2) If unable to take orally / unconscious: IM/SC glucagon 1 mg or call EMS for IV D50W; lateral position; airway monitoring.
(3) EXTENDED OBSERVATION: sulfonylurea-induced hypoglycemia often recurs (8-24 h) — admission for IV dextrose infusion (D5W or D10W) and serial BG monitoring; octreotide IV/SC may be used to suppress further insulin release.
(4) Identify cause: missed meal, dose error, drug interaction, renal decline.
(5) Provider review: dose reduction, switch to safer agent (DPP-4, GLP-1, SGLT-2, metformin), monitor renal function.
(6) Patient/family education: never skip meals after sulfonylurea, watch hypoglycemia signs, glucose tablets in pocket.

Other options: 16 oz juice with extra sugar gives way more than 15 g·potential rebound hyperglycemia. Holding next dose only ignores risk of recurrence within hours. Adding 10 mg glipizide is dangerous — would cause more severe hypoglycemia.

## In-depth explanation

Clinical reasoning summary
Sulfonylurea-induced hypoglycemia — extended observation
Sulfonylureas (glipizide, glyburide, glimepiride) stimulate pancreatic beta cells to secrete insulin and can cause prolonged, recurrent hypoglycemia, especially in:
• Elderly (impaired counter-regulation, slower drug clearance).
• Missed meal.
• Renal/hepatic impairment.
• Drug interactions (sulfa, beta-blockers, alcohol).

Glyburide has the longest half-life and is generally avoided in the elderly per Beers list.

Management of severe sulfonylurea hypoglycemia:
(1) 15-15 rule if alert and swallows safely: 15 g rapid carb, recheck in 15 min, repeat if needed.
(2) If unable to take orally / unconscious: IM/SC glucagon 1 mg or call EMS for IV D50W; lateral position; airway monitoring.
(3) EXTENDED OBSERVATION: sulfonylurea-induced hypoglycemia often recurs (8-24 h) — admission for IV dextrose infusion (D5W or D10W) and serial BG monitoring; octreotide IV/SC may be used to suppress further insulin release.
(4) Identify cause: missed meal, dose error, drug interaction, renal decline.
(5) Provider review: dose reduction, switch to safer agent (DPP-4, GLP-1, SGLT-2, metformin), monitor renal function.
(6) Patient/family education: never skip meals after sulfonylurea, watch hypoglycemia signs, glucose tablets in pocket.

Other options: 16 oz juice with extra sugar gives way more than 15 g·potential rebound hyperglycemia. Holding next dose only ignores risk of recurrence within hours. Adding 10 mg glipizide is dangerous — would cause more severe hypoglycemia.

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