# Stage 3 — Prioritize hypotheses. Mr. P, 56, has type 1 diabetes; his diabetic ketoacidosis resolved yesterday evening and he now receives basal-bolus subcutaneous insulin. Creatinine is 0.9 mg/dL. At 0430, during an EHR outage, he received regular insulin 100 units subcutaneously for a glucose of 286 mg/dL; the intended dose was 10 units. At 0500 he was diaphoretic, tremulous, and confused with a glucose of 38 mg/dL and received prescribed IV dextrose. At 0515 he is alert and oriented, glucose is 124 mg/dL, and SpO2 is 98% on room air. The unit's next routine glucose check is 0730, and mealtime insulin is due at 0800. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, 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=617394&lang=en  
> language: en  
> subject: Assignment/Delegation/Supervision  
> category: MOC

## Question

Stage 3 — Prioritize hypotheses. Mr. P, 56, has type 1 diabetes; his diabetic ketoacidosis resolved yesterday evening and he now receives basal-bolus subcutaneous insulin. Creatinine is 0.9 mg/dL. At 0430, during an EHR outage, he received regular insulin 100 units subcutaneously for a glucose of 286 mg/dL; the intended dose was 10 units. At 0500 he was diaphoretic, tremulous, and confused with a glucose of 38 mg/dL and received prescribed IV dextrose. At 0515 he is alert and oriented, glucose is 124 mg/dL, and SpO2 is 98% on room air. The unit's next routine glucose check is 0730, and mealtime insulin is due at 0800. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Condition

Select 1
Recurrent diabetic ketoacidosis
Ongoing hypoglycemia risk from insulin overdose
Isolated hypoglycemia fully corrected by dextrose
Transient ischemic attack with confusion

Actions to take

Select 2
Resume the unit's routine glucose check at 0730
Give IM glucagon now to prevent another low glucose
Hold 0800 mealtime insulin; notify the prescriber
Restart the insulin infusion under the DKA protocol
Recheck capillary glucose every 15 minutes

Parameters to monitor

Select 2
Capillary blood glucose
Serum beta-hydroxybutyrate
Serum potassium
Anion gap
Hemoglobin A1C

## Explanation

Regular insulin 100 units given at 0430 is still being absorbed and will keep lowering glucose for several more hours, while the IV dextrose acts only briefly, so the client remains at risk of another low. The nurse rechecks capillary glucose every 15 minutes per protocol and holds the 0800 mealtime insulin while notifying the prescriber. Capillary glucose and serum potassium track the ongoing insulin effect.

## In-depth explanation

Quick answer
Condition: ongoing hypoglycemia risk from a tenfold regular-insulin overdose. Actions: hold the 0800 mealtime insulin and notify the prescriber, and recheck capillary glucose every 15 minutes. Monitor: capillary blood glucose and serum potassium.

Why this is correct
Subcutaneous regular insulin peaks about 2 to 3 hours after injection and lasts several hours longer; a 100-unit dose given at 0430 will still be driving glucose down well after 0515, while an IV dextrose bolus is short-acting. Frequent capillary checks catch a fall early, and giving more insulin at 0800 would stack on the overdose. Insulin also moves potassium into cells, so serum potassium is the second parameter that tracks the excess-insulin effect.

Easy analogy or mental picture
A 100-unit depot under the skin is a tap left running into a sink, and the dextrose is one bucket bailed out. Until the tap runs dry, the nurse keeps checking the water level.

Memory hook
Big insulin dose, long tail: monitor for the whole duration of action.

NCLEX decision rule
After an insulin overdose, keep monitoring for the full duration of the insulin's action and hold any further insulin until the prescriber reassesses; choose parameters the insulin itself changes (glucose and potassium).

Why the other choices are wrong
Isolated, already-corrected hypoglycemia does not fit a 100-unit regular-insulin dose given 45 minutes earlier that has not yet reached its peak. Recurrent DKA and ketone or anion-gap tracking are the wrong direction: DKA resolved yesterday and the current problem is too much insulin, not too little. A transient ischemic attack is excluded because the confusion cleared as soon as glucose was corrected. Waiting for the 0730 routine check leaves more than two hours unmonitored during peak action. Glucagon is a rescue drug for a low glucose that cannot be treated orally or by IV, not a preventive dose. Restarting an insulin infusion adds insulin to an overdose. Hemoglobin A1C reflects months of control, not the next few hours.

References
1American Diabetes Association — Hypoglycemia (Low Blood Glucose)Recognition, treatment, and rechecking of low blood glucose
2ISMP — List of Error-Prone Abbreviations, Symbols, and Dose Designations'U' for units mistaken for a zero, causing tenfold insulin overdoses
3ISMP — High-Alert Medications in Acute Care SettingsInsulin is a high-alert medication requiring added safeguards

## Clinical scenario

Case update
0515: glucose 124 mg/dL after IV dextrose for a 38 mg/dL low caused by a tenfold regular-insulin dose given 45 minutes earlier.

## Key concepts

- **Regular insulin** — Short-acting insulin; subcutaneously it begins in about 30 minutes, peaks in 2 to 3 hours, and lasts several hours.
- **Level 3 hypoglycemia** — Low glucose with altered mental or physical function that requires help from another person to treat.
- **Error-prone abbreviation** — A notation such as 'U' for units that can be misread; units should be written out.

## Related questions

- [A 67-year-old client with chronic obstructive pulmonary disease attends a routine primary …](https://mymerci.kr/pages/nclex_q.php?qn_id=360522&lang=en)
- [A registered nurse on a medical-surgical unit is delegating tasks at the start of shift. W…](https://mymerci.kr/pages/nclex_q.php?qn_id=360523&lang=en)
- [A 78-year-old male client with end-stage pancreatic cancer is enrolled in inpatient hospic…](https://mymerci.kr/pages/nclex_q.php?qn_id=362322&lang=en)
- [A nurse on a medical-surgical unit is starting a 0700 round and reviews these four assigne…](https://mymerci.kr/pages/nclex_q.php?qn_id=362403&lang=en)
- [An RN is assigning care on a medical-surgical unit to an LPN/VN and a trained unlicensed a…](https://mymerci.kr/pages/nclex_q.php?qn_id=362464&lang=en)
- [A registered nurse on a medical-surgical unit is assigning tasks to a licensed practical n…](https://mymerci.kr/pages/nclex_q.php?qn_id=363932&lang=en)
- [A charge nurse on a medical-surgical unit is making assignments for the day shift. The tea…](https://mymerci.kr/pages/nclex_q.php?qn_id=363953&lang=en)
- [A nurse manager is reviewing situations from the past week to identify potential HIPAA Pri…](https://mymerci.kr/pages/nclex_q.php?qn_id=364050&lang=en)

## Read in another language

- [en](https://mymerci.kr/pages/nclex_q.php?qn_id=617394&lang=en)
- [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=617394&lang=ko)
- [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=617394&lang=ja)
- [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=617394&lang=zh-tw)
- [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=617394&lang=vi)

---

More free questions: [NCLEX-RN Practice](https://mymerci.kr/pages/nclex_bank.php?lang=en)

_For study reference only. Always follow current clinical guidelines and your institution’s protocols._