# A 58-year-old client with type 2 diabetes mellitus is scheduled for an exploratory laparotomy in 2 hours due to suspected bowel obstruction. The client has been NPO since midnight and typically takes metformin 1000 mg twice daily and glipizide 10 mg once daily. Current vital signs are: BP 142/88 mmHg, HR 96 bpm, RR 20/min, T 99.2°F (37.3°C). Blood glucose level is 180 mg/dL. The anesthesiologist has ordered to hold all oral diabetic medications preoperatively. What is the nurse's priority action? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=540484 > language: ko > subject: Adult Health ## 문제 A 58-year-old client with type 2 diabetes mellitus is scheduled for an exploratory laparotomy in 2 hours due to suspected bowel obstruction. The client has been NPO since midnight and typically takes metformin 1000 mg twice daily and glipizide 10 mg once daily. Current vital signs are: BP 142/88 mmHg, HR 96 bpm, RR 20/min, T 99.2°F (37.3°C). Blood glucose level is 180 mg/dL. The anesthesiologist has ordered to hold all oral diabetic medications preoperatively. What is the nurse's priority action? ## 보기 1. Administer the client's regular morning dose of metformin and glipizide as scheduled 2. Contact the physician to discuss insulin coverage for the elevated blood glucose **✔ 정답** 3. Continue to monitor blood glucose levels every 4 hours until surgery 4. Document the elevated glucose level and proceed with surgical preparation **정답: 2** ## 해설 Diabetic clients undergoing surgery require careful glucose management. With oral medications held and blood glucose elevated at 180 mg/dL, insulin coverage is needed to prevent perioperative hyperglycemia complications. This question evaluates priority nursing actions for a diabetic client undergoing surgery, focusing on perioperative blood glucose management. The client's blood glucose of 180 mg/dL is significantly above the normal fasting glucose range (70-110 mg/dL). With oral diabetic medications held as instructed by anesthesia, the client has no means of glucose control. Metformin is stopped 24-48 hours before surgery due to lactic acidosis risk, and sulfonylureas like glipizide are held to prevent hypoglycemia during fasting. Perioperative hyperglycemia (blood glucose >180 mg/dL) significantly increases surgical risks including delayed wound healing, increased infection rates, impaired immune function, and cardiovascular complications. The surgical stress response naturally elevates blood glucose through cortisol and catecholamine release, making glucose control more challenging. The priority nursing action is to contact the physician to request an insulin prescription. Most healthcare facilities use sliding-scale insulin protocols or continuous insulin infusions for perioperative diabetes management. Insulin is the only medication that can effectively lower blood glucose when oral agents are contraindicated. This is a critical thinking question where the nurse must prioritize patient safety over simple monitoring or documentation. The combination of elevated blood glucose and held oral medications creates an urgent need for alternative glucose management to prevent serious perioperative complications. ## 심화 해설 Understanding the Clinical Scenario A client with type 2 diabetes on metformin and a sulfonylurea (glipizide) is awaiting urgent surgery. The blood glucose is elevated at 180 mg/dL, and the client is NPO with orders to hold oral medications. The priority action must address the immediate risk of perioperative hyperglycemia while avoiding the dangers of giving oral agents to an NPO patient at risk for bowel obstruction. Why Holding Oral Medications Is Correct Administering the regular oral medications (Option 1) is contraindicated. The client is NPO and has a suspected bowel obstruction, making oral intake unsafe. More critically, continuing metformin in the perioperative period carries a risk of lactic acidosis, a rare but serious complication, especially in the context of potential dehydration, altered hemodynamics, or contrast dye exposure during surgery [2]. Glipizide, a sulfonylurea, stimulates insulin secretion and can cause hypoglycemia when the client is NPO, a dangerous situation under anesthesia where symptoms are masked [2]. The anesthesiologist’s order to hold these medications is consistent with best-practice perioperative management to prevent these adverse effects [2]. Why Contacting the Physician Is the Priority The core issue is managing the elevated blood glucose of 180 mg/dL without oral agents. The American Diabetes Association’s Standards of Care emphasizes that in the hospital setting, particularly perioperatively, a basal-bolus insulin regimen is the preferred method for glycemic control, and oral noninsulin medications should be held in most surgical scenarios [1]. The nurse’s priority is to recognize that a new order for insulin coverage is needed to correct the hyperglycemia and maintain euglycemia during the NPO and intraoperative period. Simply monitoring (Option 3) or documenting (Option 4) without intervening fails to address the active problem of hyperglycemia, which is associated with poor surgical outcomes including infection and fluid/electrolyte imbalances [1][2]. Contacting the physician (Option 2) is the essential step to bridge the gap between the held oral medications and the client’s current need for glycemic control, ensuring a safe transition to appropriate insulin therapy.References (research sources) - [1]16. Diabetes Care in the Hospital: Standards of Care in Diabetes-2026.Research articleAmerican Diabetes Association Professional Practice Committee for Diabetes* . (2026) · DOI: 10.2337/dc26-s016 - [2]Anti-Hyperglycemic Medication Management in the Perioperative Setting: A Review and Illustrative Case of an Adverse Effect of GLP-1 Receptor Agonist.Research articleGoron AR, Connolly C, Valdez-Sinon AN, Hesson A, Helou C, Kirschen GW. (2024) · DOI: 10.3390/jcm13206259 ## 임상 시나리오 Perioperative Diabetes Medication ManagementPrioritizing Insulin Over Oral Agents in NPO Patients For a patient with type 2 diabetes who is NPO before surgery, all oral antidiabetic agents must be held. The priority for managing hyperglycemia is to contact the provider for insulin coverage, typically a basal-bolus regimen. Continuing metformin perioperatively carries a risk of lactic acidosis, especially with potential dehydration or contrast dye exposure. Sulfonylureas like glipizide can cause dangerous, masked hypoglycemia under anesthesia. CautionNever administer oral medications to an NPO patient, particularly with a suspected bowel obstruction. A blood glucose of 180 mg/dL requires intervention, not just monitoring, to prevent perioperative complications. ## 핵심 개념 - **Lactic acidosis** — A rare but serious complication of metformin use, risk is increased with dehydration or hemodynamic instability, making it contraindicated perioperatively. - **Sulfonylurea** — A class of oral antidiabetic drugs, like glipizide, that stimulate insulin secretion and can cause hypoglycemia, especially in NPO patients. - **Basal-bolus insulin regimen** — A preferred method for managing hyperglycemia in hospitalized patients, using long-acting insulin for baseline needs and rapid-acting insulin for meals or correction. - **NPO** — Nil Per Os, meaning nothing by mouth, a standard preoperative order to reduce the risk of aspiration, which precludes oral medication administration. ## 같은 주제 문제 - [A nurse is conducting a preoperative assessment on a 22-year-old client with type 1 diabet…](https://mymerci.kr/pages/nclex_q.php?qn_id=540471) - [A nurse is caring for a diabetic client scheduled for Tonsillectomy in the morning. 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