Diabetes and Endocrine Care: Practice Questions & Explanations

The 'Rule of 15' is the standard treatment for hypoglycemia in a conscious, swallowing client: (1) Give 15 grams of fast-acting carbohydrate — options include 4 oz fruit juice, 4 oz regular (not diet) soda, 1 tbsp honey or sugar, 3-4 glucose tablets, 8 oz milk; (2) Wait 15 minutes; (3) Recheck blood glucose; (4) If still below 70 mg/dL, repeat the 15 grams of carbohydrate; (5) Once normal, give a snack with complex carbohydrate and protein to prevent recurrence (e.g., crackers with cheese, half a sandwich) if the next meal is more than an hour away. For unconscious clients: never give anything by mouth; administer IM/SQ glucagon (1 mg) if available, IV dextrose (D50) if access available, or call EMS. Common causes of hypoglycemia: too much insulin or oral hypoglycemic, missed meal, increased exercise, alcohol.

Type 1 diabetes (formerly juvenile/insulin-dependent diabetes): autoimmune destruction of pancreatic beta cells leads to absolute insulin deficiency. Onset usually in childhood/young adulthood but can occur at any age. Always requires insulin therapy. About 5-10% of diabetes cases. Higher risk of DKA. Symptoms typically develop quickly. Type 2 diabetes (formerly adult-onset/non-insulin-dependent): insulin resistance plus relative insulin deficiency. Onset typically in adulthood, but increasingly seen in younger people due to obesity. Strong association with obesity, sedentary lifestyle, family history. About 90-95% of diabetes cases. May be managed initially with diet, exercise, and oral medications (metformin first-line); often progresses to require insulin over years. Higher risk of HHS (hyperosmolar hyperglycemic state) than DKA. Symptoms often develop gradually. Both types have similar long-term complications: retinopathy, nephropathy, neuropathy, cardiovascular disease.

Regular insulin (Humulin R, Novolin R) is the short-acting insulin. Approximate pharmacokinetics: onset 30-60 minutes, peak 2-4 hours, duration 5-8 hours. Give 30 minutes before meals. The only insulin that can be given IV (for DKA, hyperkalemia, perioperative use). Other insulin types: Rapid-acting (lispro, aspart, glulisine): onset 10-15 min, peak 1-2 hr, duration 3-5 hr — give within 15 min of eating. Intermediate-acting (NPH/Humulin N): onset 1-2 hr, peak 4-12 hr, duration 14-24 hr — cloudy appearance, mix gently before drawing up. Long-acting (glargine/Lantus, detemir/Levemir): onset 1-2 hr, no pronounced peak, duration 24 hr — never mix with other insulins, give once daily. Ultra-long acting (degludec/Tresiba): duration >40 hr. NCLEX commonly tests insulin onset/peak/duration because peak times are when hypoglycemia risk is highest, and timing relative to meals is critical for blood sugar control.

SEVERE HYPOGLYCAEMIA in an UNRESPONSIVE patient requires PARENTERAL glucose administration. Attempting to give anything orally to an unresponsive patient risks ASPIRATION — a life-threatening complication. BLOOD GLUCOSE OF 32 mg/dL: Severe hypoglycaemia (normal fasting glucose 70-100 mg/dL); symptoms at this level: confusion, unresponsiveness, seizure; brain damage and death can occur within minutes without treatment.

Treatment decision tree: UNRESPONSIVE/CANNOT SWALLOW (this scenario):

IV access available: D50W (50% dextrose) 25-50 mL IV push per order — rapid and definitive.

No IV access: Glucagon 1 mg IM or SubQ — stimulates glycogenolysis (liver breaks down glycogen to glucose); takes 10-15 minutes to work; requires glycogen stores to be present (ineffective if glycogen depleted, e.g., alcohol intoxication, prolonged starvation).

Conscious with ability to swallow: 15 grams of fast-acting carbohydrates (Rule of 15): 4 oz orange juice; regular soda (not diet); glucose tablets; gel.

After treatment: Recheck blood glucose in 15 minutes; if still below 70 mg/dL, repeat treatment; once above 70 mg/dL and patient is alert, give a complex carbohydrate + protein snack to prevent recurrence; investigate the cause of the hypoglycaemic episode; adjust insulin regimen as ordered.

This client has HYPOGLYCEMIA (blood glucose below 70 mg/dL with symptoms: diaphoresis, shakiness, confusion, tachycardia, hunger). The priority is to give a FAST-ACTING CARBOHYDRATE — about 15 grams (4 oz juice, glucose tablets, regular soda, or hard candy) if the client is CONSCIOUS and able to swallow. NCLEX physiological/endocrine. THE '15-15 RULE': give 15 g of carbs, wait 15 minutes, recheck glucose; repeat if still low. If the client is UNCONSCIOUS or unable to swallow, give IV dextrose (D50) or IM/subcutaneous glucagon. NEVER give insulin (would worsen hypoglycemia). Hypoglycemia is an emergency — the brain needs glucose. Treating hypoglycemia with fast-acting carbs is a critical, heavily tested NCLEX concept.

DIABETIC KETOACIDOSIS (DKA) — a life-threatening complication mainly of type 1 diabetes with hyperglycemia, ketosis, and metabolic acidosis — is treated with: (1) IV FLUIDS (the client is severely dehydrated — fluid replacement is a priority); (2) IV REGULAR INSULIN (the only insulin given IV — to lower glucose and stop ketone production); (3) ELECTROLYTE monitoring/replacement, especially POTASSIUM (insulin drives potassium into cells, causing hypokalemia — monitor closely and replace as needed). NCLEX physiological/endocrine. Signs of DKA: high glucose, fruity breath (acetone), Kussmaul respirations (deep/rapid breathing), nausea/vomiting, dehydration. Treat the underlying cause. Knowing DKA management (fluids, IV regular insulin, potassium monitoring) is a heavily tested NCLEX concept.