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Difficulty: MediumPharmacological and Parenteral Therapies

A registered nurse is preparing to administer a mixed dose of NPH and regular insulin to a client with diabetes mellitus. In what order should the nurse perform the following actions to safely prepare the injection? Arrange the steps in the correct sequence.

  1. 1Gently roll the vial of NPH insulin between the palms of the hands.
  2. 2Cleanse the rubber stoppers of both insulin vials with alcohol swabs.
  3. 3Inject a volume of air equal to the prescribed dose into the NPH insulin vial.
  4. 4Inject a volume of air equal to the prescribed dose into the regular insulin vial.
  5. 5Withdraw the prescribed dose of regular insulin into the syringe.
  6. 6Insert the needle into the NPH insulin vial and withdraw the prescribed dose of NPH insulin.

Answer

The correct sequence is: roll the NPH vial, cleanse both stoppers, inject air into the NPH vial, inject air into the regular insulin vial, withdraw the regular insulin, and finally withdraw the NPH insulin.
When mixing regular (short-acting, clear) and NPH (intermediate-acting, cloudy) insulin in the same syringe, the nurse must prevent contamination of the regular insulin with the NPH insulin. The correct process follows the 'clear before cloudy' principle. First, the NPH vial is rolled to suspend the particles safely. Both stoppers are cleansed to maintain asepsis. Air is injected into the NPH vial first, then into the regular vial, to equalize pressure without mixing the liquids. The nurse then withdraws the regular (clear) insulin first, followed by the NPH (cloudy) insulin.

Step-by-Step Solution

1
Gently roll the vial of NPH insulin between the palms of the hands.
The suspension is mixed evenly without creating froth.
NPH insulin is a suspension that must be mixed before use; shaking vigorously can cause bubbles that lead to inaccurate dosing.
2
Cleanse the rubber stoppers of both insulin vials with alcohol swabs.
The entry points on the vials are disinfected.
Prevents the introduction of microorganisms into the sterile medication vials.
3
Inject a volume of air equal to the prescribed dose into the NPH insulin vial.
Pressure is equalized in the NPH vial without the needle touching the insulin.
Injecting air prevents a vacuum. Doing this first in the NPH vial prevents accidental contamination later.
4
Inject a volume of air equal to the prescribed dose into the regular insulin vial.
Pressure is equalized in the regular insulin vial.
Prepares the regular insulin vial for immediate withdrawal of the medication.
5
Withdraw the prescribed dose of regular insulin into the syringe.
The short-acting (clear) insulin is drawn into the syringe first.
Drawing the clear insulin first prevents it from being contaminated by the longer-acting NPH insulin.
6
Insert the needle into the NPH insulin vial and withdraw the prescribed dose of NPH insulin.
The intermediate-acting (cloudy) insulin is added, completing the combined dose.
This final step ensures both insulins are accurately mixed in one syringe without altering the rapid action profile of the regular insulin.

Key Concept

Insulin Mixing Sequence (Clear before Cloudy)
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Topics

Pharmacological and Parenteral Therapies

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