A nurse is assessing a client who is experiencing profuse vomiting.

Upon admission, the client's vital signs were within the expected reference range, but now the client's blood pressure is 86/58 mm Hg, his pulse is 114/min and weak, and his respiratory rate is 27/min.

The client appears restless and anxious and states that he thinks he is dying.

Which of the following actions should the nurse take first?

Choice A rationale

Regular insulin is a rapid-acting insulin, and NPH is an intermediate-acting insulin. When mixed in the same syringe, the regular insulin molecules can bind to the protamine in the NPH suspension. This can alter the absorption profile of the regular insulin, delaying its onset of action. Administering the mixture within 5 minutes prevents this molecular interaction and ensures the regular insulin retains its rapid-acting properties.

Choice B rationale

It is crucial to inject air into the NPH insulin vial first, followed by the regular insulin vial, and then withdraw the regular insulin dose before the NPH. This specific order prevents the NPH from contaminating the regular insulin vial with protamine, which would alter the potency and action profile of the regular insulin for future use. The regular insulin is then drawn up first.

Choice C rationale

The correct procedure is to withdraw the regular insulin before the NPH insulin. The sequence is to inject air into both vials, then draw up the clear, rapid-acting regular insulin first, followed by the cloudy, intermediate-acting NPH insulin. This sequence is essential to prevent contamination of the regular insulin vial with the NPH insulin, which could affect its rapid-acting properties.

Choice D rationale

Shaking insulin vials is generally discouraged as it can lead to the formation of air bubbles, which can result in an inaccurate dose. Instead of shaking, the NPH insulin vial should be gently rolled between the palms of the hands. This action warms the insulin and resuspends the particles uniformly without causing bubbles, ensuring an accurate and consistent dose is administered. .

Choice A rationale

Ketonuria, the presence of ketones in the urine, is typically associated with hyperglycemia and diabetic ketoacidosis. When glucose levels are high and cells can't use it for energy, the body starts breaking down fats, producing ketones as a byproduct. A blood glucose reading of 64 mg/dL is low and indicates hypoglycemia, not hyperglycemia.

Choice B rationale

Warm skin is a sign of vasodilation, often associated with a fever or an inflammatory response. In the context of hypoglycemia, the sympathetic nervous system is activated, leading to vasoconstriction, which would typically cause the skin to feel cool and clammy, not warm.

Choice C rationale

Nervousness is a common symptom of hypoglycemia. When blood glucose levels drop, the body releases counterregulatory hormones like epinephrine and norepinephrine from the adrenal glands. This sympathetic nervous system activation causes symptoms such as nervousness, anxiety, palpitations, and tremors as the body attempts to raise blood sugar.

Choice D rationale

Tachypnea, or rapid breathing, is a clinical finding associated with metabolic acidosis, such as diabetic ketoacidosis (DKA). In DKA, the body tries to compensate for the high acid load by increasing the respiratory rate to blow off carbon dioxide. It is not a typical symptom of hypoglycemia, which is indicated by a reading of 64 mg/dL. .