# A client with type 2 diabetes has scheduled orders for NPH insulin 18 units and regular insulin 8 units subcutaneously at 0730 before breakfast. At 0715 the capillary glucose is 92 mg/dL, and the nurse learns the client has been made NPO for an endoscopy now scheduled for 1300. The insulin orders have no hold parameters. Which actions should the nurse take? Select all that apply.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=617298&lang=en  
> language: en  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PPT

## Question

A client with type 2 diabetes has scheduled orders for NPH insulin 18 units and regular insulin 8 units subcutaneously at 0730 before breakfast. At 0715 the capillary glucose is 92 mg/dL, and the nurse learns the client has been made NPO for an endoscopy now scheduled for 1300. The insulin orders have no hold parameters. Which actions should the nurse take? Select all that apply.

1

Give the NPH dose now and hold the regular insulin until the client eats

2

Hold all insulin until the client is eating again after the endoscopy

3

Give both insulin doses as ordered because the glucose is above 70 mg/dL

4

Check the capillary glucose every 4 to 6 hours while the client is NPO

5

Contact the provider about both insulin doses before giving either one

## Explanation

Prandial regular insulin should not be given without a meal, and intermediate-acting NPH usually needs a dose reduction while NPO, so the nurse clarifies both doses with the provider before giving either. Capillary glucose is checked every 4 to 6 hours while NPO. Giving both doses risks hypoglycemia, while holding all insulin or choosing a partial dose independently changes the regimen without an order.

## In-depth explanation

Quick answer
Clarify both insulin doses with the provider and check glucose every 4 to 6 hours while NPO.

Why this is correct
The detail that changes everything is the new NPO status with no hold parameters. Regular insulin covers a meal that is not coming, and full-dose NPH peaks in 4 to 12 hours while the client is fasting, so a glucose of 92 mg/dL could fall into the hypoglycemic range. In hospital care, basal insulin is usually continued at a reduced dose when NPO, but that dose is a prescriber decision, so the nurse contacts the provider rather than adjusting the order alone.

Easy analogy or mental picture
Regular insulin is a dinner reservation: if the meal is cancelled, you cancel the reservation, and you ask the manager (provider) how to handle the standing booking (NPH).

Memory hook
NPO + insulin = call before you inject.

NCLEX decision rule
When a client's intake changes and insulin orders lack hold parameters, clarify with the prescriber and increase glucose monitoring.

Why the other choices are wrong
Giving both doses is tempting because the glucose is above the usual hold threshold of 70 mg/dL, but that threshold assumes the client will eat. Giving NPH and holding regular is clinically close to what the provider may choose, which makes it very tempting, yet it is an independent change to the order and the NPH may need a reduced dose. Holding all insulin avoids hypoglycemia but can cause hyperglycemia and ketosis; stopping basal coverage is also a prescriber decision.

References
1ADA Standards of Care in Diabetes—2025 (Diabetes Care Supplement 1)Diabetes care in the hospital: glucose monitoring every 4 to 6 hours when NPO and basal insulin adjustment
2Institute for Safe Medication Practices (ISMP)Insulin as a high-alert medication and safe administration practices

## Clinical scenario

Scenario
Type 2 diabetes on scheduled NPH plus regular insulin before breakfast; newly NPO for a 1300 endoscopy with a fasting glucose of 92 mg/dL and no hold parameters.

## Key concepts

- **NPH insulin** — Intermediate-acting insulin with onset in 1 to 2 hours and peak effect 4 to 12 hours after injection.
- **Prandial insulin** — Short- or rapid-acting insulin given to cover carbohydrate from a meal.
- **Hold parameter** — An order-specified condition under which a scheduled dose is withheld.

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