1. You have a patient in the medical surgical unit who has an order for 20u of NPH at 9am. What is the most likely time hypoglycemia will occur and why? (3 points)
2. You are caring for a diabetic patient who has an NPO order (nothing by mouth) before surgery which is scheduled at 1000. The patient typically receives 30 units of Humulin 70/30 every morning at 0700. Given the above scenario please explain what you would do next. In other words do you give the insulin as ordered? Why or why not (please provide rationale) (2 points)
3. Mr H is a 132 pound male status post coronary artery bypass surgery post-op day #1.
   He has the following medical history:
   • Hypertension
   • Type II diabetes
   • Coronary artery disease
   • Hyperlipidemia (high cholesterol)
   • Chronic kidney disease

Patient exam: He is awake, alert and oriented. His speech is clear and appropriate. He is having some incisional pain with pain rating of 7/10. His incision is clean, dry and intake. For this case study the rest of his exam in normal.

Home Medications:
• Metformin 1000mg daily
• Sitagliptin phosphate (Januvia) 100mg daily
• Lisinopril 10mg daily
• Metoprolol 50mg once a day
• Atorvastatin 40mg daily

He is currently in the Intensive Care Unit. You (the nurse) note that Mr H’s fasting blood glucose level was elevated this morning with a value of 450.
You call the surgical resident and the resident prescribes the following:
IV infusion of regular insulin at 0.1 units/kg/hour, which calculates to 6 units per hour.
The insulin comes mixed as a solution of 25 units in 100ml of normal saline. The IV pump calibration is in milliliters per hour. (3 pts)
Using the above scenario please answer the following questions:
a. What rate should you program the IV pump for the continuous IV insulin drip?
b. What are some safety considerations when administering IV insulin?

4. On post-op day 3 the insulin drip was discontinued and his home medications for his diabetes was re-ordered.
   a. You are conducting the medication reconciliation. Briefly describe the mechanism of action for each of the diabetic agents listed in the patients home medication list. (4 pts)
   b. Please list at least 2 adverse effects for the medications you identified in the previous question (question 4a) (2 pts)
   c. Referring to the medication(s) you referenced again in question 4a please identify at least one important consideration when teaching your patient about medication safety. (1 pt)