# The 68-year-old client with type 2 diabetes and stage 3 chronic kidney disease, admitted for pneumonia that is improving on room air, ate 25% of dinner. Capillary glucose was 102 mg/dL at 1600 and 78 mg/dL at 2030. The client is alert, oriented, and denies palpitations or sweating. The 2100 medication administration record lists 2 active orders: insulin degludec 24 units subcutaneously and insulin glargine 20 units subcutaneously. The client reports using degludec 24 units at bedtime at home and has never used 2 long-acting insulins together. There is no order for correction insulin at bedtime. Blood pressure is 126/72 mm Hg. Complete the diagram by selecting the problem the client is most likely experiencing, 2 actions the nurse should take to address that problem, and 2 parameters the nurse should monitor to assess the client's progress.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=617374&lang=en  
> language: en  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PPT

## Question

The 68-year-old client with type 2 diabetes and stage 3 chronic kidney disease, admitted for pneumonia that is improving on room air, ate 25% of dinner. Capillary glucose was 102 mg/dL at 1600 and 78 mg/dL at 2030. The client is alert, oriented, and denies palpitations or sweating. The 2100 medication administration record lists 2 active orders: insulin degludec 24 units subcutaneously and insulin glargine 20 units subcutaneously. The client reports using degludec 24 units at bedtime at home and has never used 2 long-acting insulins together. There is no order for correction insulin at bedtime. Blood pressure is 126/72 mm Hg. Complete the diagram by selecting the problem the client is most likely experiencing, 2 actions the nurse should take to address that problem, and 2 parameters the nurse should monitor to assess the client's progress.

Condition

Select 1
Intended split-dose basal insulin regimen
Formulary substitution of one basal insulin
Hypoglycemia from reduced dinner intake
Unintended duplicate basal insulin orders

Actions to take

Select 2
Give only the degludec dose, as used at home
Hold both basal insulin doses until clarified
Contact the prescriber and pharmacist to reconcile
Give 15 g of oral carbohydrate now
Give only the glargine dose, as the formulary product

Parameters to monitor

Select 2
Capillary blood glucose
Urine ketones
Hemoglobin A1c
Serum creatinine and estimated GFR
Tremor, sweating, and confusion

## Explanation

Two active long-acting insulin orders for a client who uses only one at home is an unintended duplication, a high-alert medication error. With poor intake, a falling glucose, and CKD, either dose given without clarification could cause severe nocturnal hypoglycemia, so the nurse holds both and reconciles with the prescriber and pharmacist. Glucose and hypoglycemia symptoms are then trended overnight.

## In-depth explanation

Quick answer
Unintended duplicate basal insulin orders. Actions: hold both basal insulin doses until clarified; contact the prescriber and pharmacist to reconcile. Monitor: capillary blood glucose, and tremor, sweating, and confusion.

Why this is correct
Degludec and glargine are both basal insulins; having both active is a therapeutic duplication. The client's home regimen confirms only one was intended. The nurse cannot choose which order is correct, because the dose may need reduction for reduced intake and CKD, which slows insulin clearance. Closed-loop reconciliation with the prescriber and pharmacist resolves the error before any dose is given.

Easy analogy or mental picture
Two pilots grabbing the same steering wheel: before the plane moves, the tower (prescriber and pharmacist) must decide who flies, and the nurse keeps both hands off until then.

Memory hook
Two basals = zero until clarified.

NCLEX decision rule
When a high-alert medication order is duplicated or unclear, withhold it and clarify with the prescriber; do not resolve the discrepancy by choosing a dose on your own or by asking the client to choose.

Why the other choices are wrong
An intended split regimen would use one basal product twice, not 2 different basal products the client never used together. A formulary substitution would replace one order, not leave both active. Glucose 78 mg/dL is not yet hypoglycemia (below 70 mg/dL) and the client is asymptomatic, so 15 g of carbohydrate treats a problem that has not occurred and ignores the order error. Giving only degludec or only glargine is tempting but is an independent prescribing decision. Urine ketones, A1c, and creatinine do not track the overnight hypoglycemia risk.

References
1AHRQ MATCH Toolkit for Medication Reconciliation — Chapter 5Discrepancies between home and inpatient orders are resolved by verifying sources and contacting the prescriber.

## Clinical scenario

Case update
At 2030 the client with CKD has eaten 25% of dinner and glucose has fallen to 78 mg/dL, while 2 long-acting insulin orders (degludec and glargine) are both active for 2100.

## Key concepts

- **Therapeutic duplication** — Two active orders for drugs of the same class that together exceed the intended therapy.
- **Basal insulin** — Long-acting insulin such as glargine or degludec that provides background insulin over about 24 hours or longer.
- **Medication reconciliation** — Comparing the home medication list with admission orders to identify and resolve discrepancies.

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