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Difficulty: MediumPharmacological Therapies

While preparing a client's morning medications, a practical nurse needs to combine prescribed doses of regular insulin and NPH insulin into one syringe. Place the actions required to safely prepare this mixed insulin injection into the correct chronological sequence.

  1. 1Roll the vial of NPH insulin gently between the palms of the hands.
  2. 2Inject a volume of air equal to the prescribed dose into the NPH insulin vial.
  3. 3Inject a volume of air equal to the prescribed dose into the regular insulin vial.
  4. 4Withdraw the prescribed dose of regular insulin into the syringe.
  5. 5Withdraw the prescribed dose of NPH insulin into the syringe.

Answer

The correct sequence is to roll the NPH vial, inject air into the NPH vial, inject air into the regular insulin vial, withdraw the regular insulin, and finally withdraw the NPH insulin.
The standard procedure for mixing insulins dictates that the intermediate-acting NPH insulin (cloudy) must be gently rolled first to mix the suspension. To avoid negative pressure without contaminating the needle, air is injected into the NPH vial first, followed by injecting air into the regular insulin (clear) vial. The regular insulin is then withdrawn first ('clear before cloudy') to ensure that no intermediate-acting insulin accidentally contaminates the rapid or short-acting regular insulin vial. Finally, the NPH insulin is withdrawn.

Step-by-Step Solution

1
Roll the vial of NPH insulin gently between the palms of the hands.
The cloudy insulin suspension is mixed uniformly.
NPH insulin is a suspension that settles. Rolling mixes it gently without creating bubbles that could lead to an inaccurate dose.
2
Inject a volume of air equal to the prescribed dose into the NPH insulin vial.
The NPH vial is pressurized.
Injecting air first prevents the creation of a vacuum later. The needle touches only air, remaining uncontaminated for the next vial.
3
Inject a volume of air equal to the prescribed dose into the regular insulin vial.
The regular insulin vial is pressurized.
The regular insulin vial must be pressurized immediately before drawing up the medication.
4
Withdraw the prescribed dose of regular insulin into the syringe.
The clear insulin is drawn into the syringe.
The clear (regular) insulin is always drawn first to prevent the cloudy (NPH) insulin from entering and contaminating the regular insulin vial.
5
Withdraw the prescribed dose of NPH insulin into the syringe.
The exact dose of cloudy insulin is added to the syringe.
The cloudy insulin is drawn last to complete the mixture. If too much NPH is drawn inadvertently, the entire syringe must be discarded as the insulins are already mixed.

Key Concept

Safe Preparation of Mixed Insulins (Clear before Cloudy)
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Topics

Pharmacological Therapies

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