7.3 High-Alert Medications: Insulins

NCLEX-RN Registered Nurse

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1 Introduction

About the NCLEX-RN Exam Next Generation NCLEX (NGN) Clinical Judgment Measurement Model (NCJMM) How to Use This Course

2 Chapter 2: Management of Care

2.1 Legal Rights and Responsibilities 2.2 Advance Directives and Self-Determination 2.3 Informed Consent Protocols 2.4 Client Advocacy and Rights (HIPAA) 2.5 Assignment, Delegation, and Supervision 2.6 Five Rights of Delegation 2.7 Scope of Practice (RN vs LPN vs UAP) 2.8 Ethical Practice Principles

3 Chapter 3: Safety and Infection Prevention and Control

3.1 Standard Precautions and Hand Hygiene 3.2 Transmission-Based Precautions (Contact, Droplet, Airborne) 3.3 PPE Donning and Doffing Sequences 3.4 Fall Prevention and Restraints 3.5 Fire Safety (RACE/PASS) 3.6 Disaster Triage and Emergency Response

4 Chapter 4: Health Promotion and Maintenance

4.1 Growth and Development (Erikson/Piaget) 4.2 Developmental Stages: Infancy through Older Adult 4.3 Maternal and Newborn Care (Antepartum) 4.4 Intrapartum Care and Fetal Monitoring 4.5 Postpartum Care (BUBBLE-HE) 4.6 Health Screening Guidelines 4.7 Immunization Schedules

5 Chapter 5: Psychosocial Integrity

5.1 Therapeutic Communication Techniques 5.2 Non-Therapeutic Communication (What to Avoid) 5.3 Anxiety Disorders and Mental Health Concepts 5.4 Schizophrenia: Hallucinations and Delusions 5.5 Depression and Suicide Assessment 5.6 Substance Misuse and Withdrawal 5.7 Grief and End-of-Life Care

6 Chapter 6: Basic Care and Comfort

6.1 Mobility and Hazards of Immobility 6.2 Assistive Devices (Crutches, Canes, Walkers) 6.3 Nutrition and Diet Therapy 6.4 Enteral Nutrition (Tube Feeding) 6.5 Bowel Elimination and Ostomy Care 6.6 Urinary Elimination and Catheter Care

7 Chapter 7: Pharmacological and Parenteral Therapies

7.1 Medication Administration Rights 7.2 Medication Calculations 7.3 High-Alert Medications: Insulins 7.4 High-Alert Medications: Anticoagulants 7.5 High-Alert Medications: Opioids 7.6 High-Alert Medications: Digoxin and Electrolytes 7.7 IV Therapy and Complications 7.8 Blood Product Administration 7.9 Total Parenteral Nutrition (TPN)

8 Chapter 8: Reduction of Risk Potential

8.1 Laboratory Values: Hematology (CBC) 8.2 Laboratory Values: Metabolic Panel (BMP) 8.3 Laboratory Values: Coagulation Studies 8.4 Vital Signs and Trend Recognition 8.5 Perioperative Care (Pre-Op and Post-Op) 8.6 Nasogastric Tubes and Therapeutic Procedures

9 Chapter 9: Physiological Adaptation

9.1 Fluid Imbalances (Hypovolemia and Hypervolemia) 9.2 Arterial Blood Gases (ABGs) and Acid-Base Balance 9.3 Medical Emergencies: Stroke (CVA) 9.4 Medical Emergencies: Myocardial Infarction (MONA) 9.5 Diabetic Emergencies (Hypoglycemia and DKA) 9.6 Respiratory Conditions (COPD, Pneumonia) 9.7 Cardiac Conditions (Heart Failure) 9.8 Neurological Conditions (Seizures)

7.3 High-Alert Medications: Insulins

Key Takeaways Explain This Topic AI

Regular insulin is the standard IV insulin; some rapid-acting analogs (such as insulin aspart) are also labeled for IV use under medical supervision, while NPH and long-acting insulins are given subcutaneously

When mixing insulins, draw "Clear before Cloudy" (Regular before NPH) to prevent contamination

Hypoglycemia signs include: cool/clammy skin, tremors, confusion, tachycardia - treat immediately with 15g fast-acting carbohydrate

Long-acting insulins (Glargine/Lantus, Detemir/Levemir) should NEVER be mixed with other insulins

Insulin is measured in units - always use an insulin syringe and have a second nurse verify high-alert doses
Last updated: October 2026

Insulin errors are among the most common and dangerous medication errors in healthcare. Understanding insulin types, administration, and monitoring is critical for the NCLEX and patient safety.

Insulin Types and Action Profiles

Type Examples Onset Peak Duration
Rapid-Acting Lispro (Humalog), Aspart (Novolog), Glulisine (Apidra) 5-15 min 30-90 min 3-5 hours
Short-Acting Regular (Humulin R, Novolin R) 30-60 min 2-4 hours 5-8 hours
Intermediate NPH (Humulin N, Novolin N) 1-2 hours 4-12 hours 12-18 hours
Long-Acting Glargine (Lantus), Detemir (Levemir) 1-2 hours No peak (flat) 24 hours
Ultra Long-Acting Degludec (Tresiba) 1 hour No peak 42+ hours
Critical Concept: Peak time = highest risk for hypoglycemia
IV Insulin Administration

Regular insulin is the standard IV insulin. Some rapid-acting analogs (for example, insulin aspart) are also labeled for IV use under medical supervision; NPH and long-acting basal insulins are given subcutaneously.

Indications for IV insulin:

Diabetic ketoacidosis (DKA)
Hyperglycemic hyperosmolar state (HHS)
Critical illness requiring tight glucose control

IV insulin requires:

Continuous cardiac monitoring
Hourly blood glucose checks
Potassium monitoring, with replacement as ordered (insulin drives K+ into cells)
Mixing Insulins: "Clear Before Cloudy"

When mixing Regular and NPH in the same syringe:

Inject air into NPH vial first (cloudy)
Inject air into Regular vial (clear)
Draw up Regular insulin first (clear)
Draw up NPH insulin (cloudy)
Mnemonic: RN - Regular before NPH, or "Clear before Cloudy"

Rationale: If NPH contaminates the Regular vial, the entire vial is compromised because the action profile becomes unpredictable.

Insulins That Should NEVER Be Mixed
Glargine (Lantus) - precipitates if mixed
Detemir (Levemir) - altered absorption if mixed
Degludec (Tresiba) - never mix

These long-acting insulins are given as separate injections.

Hypoglycemia Recognition and Treatment
Blood Glucose < 70 mg/dL = Hypoglycemia

Signs/Symptoms Body System
Tremors, shakiness Sympathetic response
Tachycardia, palpitations Cardiovascular
Diaphoresis (sweating) Autonomic
Cool, clammy skin Peripheral
Confusion, irritability CNS - early
Seizure, unconsciousness CNS - severe

Treatment Protocol (Rule of 15):

Give 15 grams of fast-acting carbohydrate
Recheck blood glucose in 15 minutes
Repeat if still < 70 mg/dL
Once > 70, give protein/complex carb snack

Fast-Acting Carbohydrate Sources (15g each):

4 oz (120 mL) juice or regular soda
3-4 glucose tablets
1 tablespoon honey or sugar
6-7 hard candies

Unconscious Patient:

Do NOT give anything by mouth (aspiration risk)
Administer Glucagon 1 mg IM/SubQ
Or Dextrose 50% (D50W) 25-50 mL IV push
Hyperglycemia Recognition

Glucose ≥ 200 mg/dL (or known diabetes) with elevated ketones and acidosis = DKA, a medical emergency (2024 adult consensus; about 10% of patients present with glucose < 200 mg/dL)

Signs of DKA:

Kussmaul respirations (deep, rapid breathing)
Fruity breath odor (ketones)
Polyuria, polydipsia, polyphagia (3 P's)
Nausea, vomiting, abdominal pain
Altered mental status
Treatment: IV Regular insulin + IV fluids + electrolyte replacement
Administration Safety

Safety Measure Rationale
Use insulin syringe Calibrated in units
Verify with 2nd nurse Independent double-check
Check expiration date Expired insulin loses potency
Rotate injection sites Prevents lipodystrophy
Store properly Opened vials room temp 28 days; unopened refrigerated
Never skip meals Prevents hypoglycemia
Timing of Administration

Insulin Type When to Give
Rapid-acting With meals or within 15 minutes of eating
Regular 30 minutes before meals
NPH Same time daily; often morning and/or bedtime
Long-acting Same time daily; often bedtime
Sliding Scale Insulin

Sliding scale provides supplemental insulin based on blood glucose readings:

Blood Glucose Regular Insulin Dose
< 150 mg/dL 0 units
150-200 mg/dL 2 units
201-250 mg/dL 4 units
251-300 mg/dL 6 units
301-350 mg/dL 8 units
> 350 mg/dL 10 units + call provider
Note: Actual scales vary by provider order
On the Exam
Know that Regular insulin is the standard IV insulin (NPH and long-acting insulins are not given IV)
Recognize hypoglycemia symptoms
Understand mixing order (clear before cloudy)
Calculate insulin doses correctly