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TPN Care And Metabolic Monitoring - NCLEX Rn

  1. A 64-year-old client with a history of heart failure is receiving TPN via central line after bowel surgery. The TPN (dextrose 20%, amino acids 5%, electrolytes) is infusing at 95 mL/hr. Assessment: new crackles in both lung bases, oxygen saturation 90% on 2 L nasal cannula, jugular venous distention, and weight gain of 1.8 kg (4 lb) in 24 hours; urine output is 25 mL/hr. What is the nurse's PRIORITY action for a client receiving TPN?
    Answer: Assess for fluid overload, maintain airway/oxygenation, and notify the provider of suspected volume overload This question tests clinical judgment in TPN care and metabolic monitoring. The priority concern is fluid overload, a risk in heart failure clients receiving high-volume TPN. Assessing for overload, maintaining airway, and notifying the provider is the highest priority to prevent pulmonary edema. Slowing without order violates policy; delegating weights is not immediate; blood cultures address infection, not overload, addressing misconceptions about volume management. Prioritizing client safety involves monitoring intake/output and lung sounds. Decision-making in TPN care emphasizes adjusting rates for comorbidities. A transferable nursing strategy is to weigh clients daily and report gains over 1 kg to avoid fluid-related complications.
  2. A 5-year-old child (history: necrotizing enterocolitis as an infant) has short bowel syndrome and is receiving TPN via a central venous catheter. The TPN is infusing continuously at 40 mL/hr and contains dextrose 15%, amino acids 3%, electrolytes, vitamins, and trace elements; lipids 20% infuse over 20 hours daily. The child has a temperature of 38.5°C (101.3°F) and is irritable; the catheter site appears normal. Which assessment finding indicates a complication of TPN therapy?
    Answer: Fever and irritability in a child with a central line receiving TPN This question tests clinical judgment in TPN care and metabolic monitoring. The priority concern is infection in pediatric clients with central lines for TPN. Fever and irritability indicate the highest priority as they suggest central line infection despite normal site appearance. Heart rate 110/min while crying is expected; capillary refill 2 seconds and urine output 1 mL/kg/hr are normal, countering misconceptions about vital sign variations. Prioritizing client safety involves early sepsis recognition. Decision-making in TPN care focuses on age-specific assessments. A transferable nursing strategy is to monitor for subtle infection signs like behavioral changes in children on TPN.
  3. A 49-year-old client with severe pancreatitis is receiving TPN via central line: dextrose 25%, amino acids 5%, electrolytes, vitamins at 90 mL/hr; lipids 20% over 12 hours. The nurse notes the TPN solution appears cloudy with visible particles in the tubing. The client is stable and afebrile. What is the nurse's PRIORITY action for a client receiving TPN?
    Answer: Stop the infusion and replace the tubing and solution per policy; do not infuse the contaminated-appearing TPN This question tests clinical judgment in TPN care and metabolic monitoring. The priority concern is contaminated TPN solution posing infection or embolism risks. Stopping the infusion and replacing tubing/solution is the highest priority to avoid infusing particles. Increasing rate worsens exposure; shaking may not resolve; flushing doesn't address source, addressing misconceptions about visual inspections. Prioritizing client safety involves discarding suspect solutions. Decision-making in TPN care emphasizes sterility checks. A transferable nursing strategy is to inspect TPN bags for clarity before hanging and report anomalies to pharmacy.
  4. A 68-year-old client with recent bowel surgery is receiving TPN through a central line at 75 mL/hr (dextrose 20%, amino acids 5%, electrolytes) with 20% lipids 250 mL over 12 hours. The client suddenly becomes confused and diaphoretic; bedside glucose is 42 mg/dL. What is the nurse's PRIORITY action for a client receiving TPN?
    Answer: Administer IV dextrose per protocol and recheck glucose in 15 minutes This question tests TPN care and metabolic monitoring clinical judgment, specifically managing acute hypoglycemia during TPN therapy. The priority concern is severe hypoglycemia (glucose 42 mg/dL) with neurological symptoms (confusion) and sympathetic response (diaphoresis), requiring immediate intervention to prevent seizures or loss of consciousness. Administering IV dextrose per protocol and rechecking glucose in 15 minutes is the highest priority to rapidly correct the dangerously low blood sugar. Stopping TPN without dextrose replacement would worsen hypoglycemia, obtaining labs delays urgent treatment, and delegation is inappropriate for this critical situation. The decision-making principle is that symptomatic hypoglycemia during TPN therapy requires immediate IV dextrose administration to prevent neurological complications. The transferable nursing strategy is to never abruptly stop TPN without ensuring alternative glucose source, as the high dextrose content can cause rebound hypoglycemia.
  5. A 66-year-old client is postoperative day 1 after bowel surgery and is receiving TPN through a central venous catheter due to anticipated prolonged NPO status. The TPN (dextrose 20%, amino acids 5%, electrolytes, vitamins) is infusing at 60 mL/hr. The infusion pump alarms "occlusion," and the client reports sudden shortness of breath and chest pain. Vital signs: heart rate 124/min, blood pressure 92/58 mm Hg, respirations 30/min, oxygen saturation 86% on room air. What is the nurse's PRIORITY action for a client receiving TPN?
    Answer: Stop the infusion, clamp the catheter, and place the client in left lateral Trendelenburg position This question tests clinical judgment in TPN care and metabolic monitoring. The priority concern is air embolism, a life-threatening complication from central line occlusion during TPN infusion. Stopping the infusion, clamping the catheter, and placing in left lateral Trendelenburg is the highest priority to prevent further air entry and promote trapping in the right atrium. Flushing may worsen embolism; X-ray is secondary; delegating vital signs delays intervention, addressing misconceptions about occlusion management. Prioritizing client safety involves immediate airway and circulatory stabilization. Decision-making in TPN care emphasizes rapid response to infusion alarms. A transferable nursing strategy is to ensure all connections are secure and respond promptly to pump alarms to prevent embolic events.
  6. A 48-year-old client with severe pancreatitis and a history of alcohol use disorder is NPO and receiving TPN through a central venous catheter. The TPN is infusing at 80 mL/hr and contains dextrose 25%, amino acids 5%, electrolytes, vitamins, and trace elements; 20% lipids are ordered at 250 mL over 12 hours. Current assessment: BP 128/76 mm Hg, HR 96/min, T 37.2°C (99.0°F); morning labs show potassium 2.9 mEq/L (normal 3.5–5.0), magnesium 1.4 mg/dL (normal 1.7–2.2), and glucose 178 mg/dL. Which lab value requires IMMEDIATE intervention for a client on TPN?
    Answer: Potassium 2.9 mEq/L This question tests TPN care and metabolic monitoring clinical judgment, focusing on recognizing critical electrolyte imbalances. The priority concern is severe hypokalemia with a potassium level of 2.9 mEq/L (normal 3.5-5.0), which poses immediate risk for cardiac dysrhythmias and requires urgent intervention. While the magnesium is also low at 1.4 mg/dL (normal 1.7-2.2) and the glucose is elevated at 178 mg/dL, the critically low potassium represents the highest priority due to its potential for life-threatening cardiac complications. The heart rate of 96/min is within acceptable limits and not indicative of immediate danger. The decision-making principle is that critically low potassium levels always require immediate intervention before addressing other electrolyte imbalances. The transferable nursing strategy is to prioritize electrolyte replacement based on cardiac risk, with potassium <3.0 mEq/L requiring immediate notification and intervention.
  7. A 28-year-old client with short bowel syndrome is preparing for discharge on home TPN after multiple bowel resections. The client will infuse TPN nightly via a tunneled central venous catheter: 2,000 mL over 12 hours (dextrose 20%, amino acids 5%, electrolytes, vitamins, trace elements) using an infusion pump; 20% lipid emulsion is infused 3 nights per week. Which assessment finding indicates a complication of TPN therapy during a home health visit?
    Answer: Fever 38.3°C (100.9°F) with chills occurring during the infusion This question tests clinical judgment in TPN care and metabolic monitoring. The priority concern is infection, a common complication in home TPN via central lines. Fever with chills during infusion indicates the highest priority as it suggests line sepsis needing prompt evaluation. Mild hunger is expected; intact dressing is positive; minimal weight gain is normal, countering misconceptions about benign symptoms. Prioritizing client safety involves teaching infection signs. Decision-making in TPN care focuses on home monitoring education. A transferable nursing strategy is to instruct clients to report fevers immediately and seek care to prevent systemic infections.
  8. A 67-year-old client is receiving TPN after bowel surgery via central venous catheter. The TPN is infusing at 75 mL/hr and contains dextrose 20%, amino acids 5%, electrolytes, vitamins, and trace elements. A new order is written: "Administer TPN through a peripheral IV in the forearm until central line is replaced." The nurse should QUESTION which TPN order?
    Answer: Administer the current TPN formulation through a peripheral IV This question tests clinical judgment in TPN care and metabolic monitoring. The priority concern is phlebitis and osmolarity risks with hypertonic TPN. Administering through peripheral IV should be questioned as TPN requires central access to avoid vein damage. Monitoring glucose, using pumps, and changing tubing are standard and appropriate, countering misconceptions about access routes. Prioritizing client safety involves proper administration sites. Decision-making in TPN care focuses on vascular access guidelines. A transferable nursing strategy is to confirm central line placement before initiating TPN to prevent peripheral complications.
  9. A 58-year-old client with Crohn's disease is postoperative after small bowel resection and is receiving TPN via a central line due to high-output nasogastric suction. The TPN is infusing at 85 mL/hr with dextrose 20%, amino acids 5%, electrolytes, vitamins, and trace elements. Current labs: phosphorus 1.6 mg/dL (low; typical 2.5–4.5 mg/dL), magnesium 1.4 mg/dL (low; typical 1.7–2.2 mg/dL), potassium 3.1 mEq/L (low). The client is weak and has new paresthesias. Which lab value requires IMMEDIATE intervention for a client on TPN?
    Answer: Phosphorus 1.6 mg/dL (low) This question tests clinical judgment in TPN care and metabolic monitoring. The priority concern is hypophosphatemia, a metabolic imbalance from refeeding syndrome in malnourished clients on TPN. Phosphorus 1.6 mg/dL requires immediate intervention as it can cause weakness, paresthesias, and respiratory failure. Calcium 9.0 mg/dL, chloride 102 mEq/L, and hemoglobin 11.2 g/dL are normal and not urgent, addressing misconceptions that all low labs are equally critical in TPN. Prioritizing client safety involves correcting phosphate deficits promptly. Decision-making in TPN care emphasizes preventing refeeding syndrome through gradual initiation. A transferable nursing strategy is to monitor electrolytes closely in the first week of TPN and supplement as needed to avoid imbalances.
  10. A 70-year-old client with a history of chronic kidney disease stage 3 is postoperative after bowel surgery and is receiving TPN via a central line due to prolonged ileus. The TPN is infusing at 70 mL/hr and contains dextrose 20%, amino acids 5%, and electrolytes. Current labs: potassium 6.1 mEq/L, creatinine 2.0 mg/dL, and ECG shows peaked T waves; vital signs are stable. Which lab value requires IMMEDIATE intervention for a client on TPN?
    Answer: Potassium 6.1 mEq/L with peaked T waves on ECG This question tests clinical judgment in TPN care and metabolic monitoring. The priority concern is hyperkalemia, exacerbated by chronic kidney disease and TPN electrolytes. Potassium 6.1 mEq/L with peaked T waves requires immediate intervention to prevent cardiac arrhythmias or arrest. Creatinine 2.0 mg/dL indicates kidney impairment but is not immediately life-threatening; magnesium 1.9 mg/dL and phosphorus 3.2 mg/dL are normal and lower priority, addressing misconceptions about electrolyte monitoring in renal patients. Prioritizing client safety involves rapid correction of life-threatening imbalances. Decision-making in TPN care emphasizes tailoring electrolytes to the client's renal function. A transferable nursing strategy is to review labs daily and adjust TPN orders promptly for electrolyte abnormalities in at-risk clients.
  11. A 59-year-old client is discharged with home TPN for radiation enteritis and has a history of depression. The client reports infusing TPN at 100 mL/hr overnight (dextrose 18%, amino acids 5%, electrolytes) and 20% lipids 250 mL three times weekly; today the client states, "Sometimes I turn the pump off for a few hours if I feel puffy." Assessment shows a 3-kg weight loss in 2 weeks, dry skin, and orthostatic BP (lying 124/78, standing 98/60). Which assessment finding indicates a complication of TPN therapy?
    Answer: Orthostatic hypotension with recent 3-kg weight loss This question tests TPN care and metabolic monitoring clinical judgment, focusing on recognizing dehydration from improper TPN management. The priority concern is dehydration evidenced by orthostatic hypotension (BP drop from 124/78 to 98/60 on standing), 3-kg weight loss, and dry skin, likely resulting from the client intermittently stopping TPN infusions. While turning off the pump is concerning behavior requiring education, receiving lipids three times weekly is appropriate, and depression history provides context but isn't the complication, the orthostatic changes indicate significant volume depletion requiring intervention. The decision-making principle is that orthostatic vital signs with weight loss in TPN clients indicate dehydration requiring fluid replacement and education about consistent infusion. The transferable nursing strategy is to educate home TPN clients about the importance of consistent infusion schedules and to monitor for signs of dehydration through weight trends and orthostatic vital signs.
  12. A 56-year-old client is receiving TPN after bowel surgery via central venous catheter. The TPN is infusing at 70 mL/hr (dextrose 20%, amino acids 5%, electrolytes, vitamins). The client reports tingling around the mouth and muscle cramps; Chvostek sign is present. Labs: calcium 7.1 mg/dL (low; typical 8.5–10.5 mg/dL), magnesium 1.3 mg/dL (low). Which lab value requires IMMEDIATE intervention for a client on TPN?
    Answer: Calcium 7.1 mg/dL (low) with neuromuscular irritability This question tests clinical judgment in TPN care and metabolic monitoring. The priority concern is hypocalcemia, a refeeding syndrome complication in TPN. Calcium 7.1 mg/dL with neuromuscular irritability requires immediate intervention to prevent tetany or seizures. BUN 22 mg/dL, sodium 137 mEq/L, and WBC 10,200/mm³ are normal and lower priority, countering misconceptions about lab monitoring. Prioritizing client safety involves electrolyte replacement. Decision-making in TPN care focuses on symptom correlation with labs. A transferable nursing strategy is to assess for Chvostek sign and supplement calcium early in malnourished clients.
  13. A 51-year-old client with ulcerative colitis is receiving TPN via central line at 95 mL/hr (dextrose 25%, amino acids 5%, electrolytes) and 20% lipids 250 mL over 12 hours daily. The provider writes new orders after morning labs: potassium chloride 80 mEq IV piggyback now, magnesium sulfate 2 g IV now, and continue TPN unchanged; current potassium is 3.4 mEq/L (normal 3.5–5.0) and magnesium is 1.6 mg/dL (normal 1.7–2.2), with stable vital signs. The nurse should QUESTION which TPN-related order?
    Answer: Potassium chloride 80 mEq IV piggyback now for potassium 3.4 mEq/L The order to question is the potassium chloride 80 mEq IV piggyback now for a potassium of 3.4 mEq/L. Although 3.4 is below the normal range (3.5–5.0), 80 mEq given as a rapid piggyback is an excessive potassium replacement and carries a risk of hyperkalemia; safe potassium replacement is rate-limited (usually 10–20 mEq/hr peripherally or up to 40 mEq/hr centrally with cardiac monitoring). Continuing the TPN unchanged while separate electrolyte replacement is given is appropriate and does not need to be questioned. Magnesium sulfate 2 g IV for a magnesium of 1.6 mg/dL is a reasonable initial dose for mild hypomagnesemia, especially with a plan to recheck after completion. Rechecking electrolytes after replacement and comparing them to the morning labs is standard monitoring. The nurse's clinical judgment is to recognize the unsafe potassium dose, not to flag appropriate replacement, continuation of TPN, or follow-up lab work.
  14. A 45-year-old client with severe pancreatitis (history of alcohol use disorder) is NPO and receiving TPN through a peripherally inserted central catheter (PICC). The TPN contains dextrose 25%, amino acids 5%, electrolytes, vitamins, and trace elements, infusing at 80 mL/hr; 20% lipid emulsion is infusing at 20 mL/hr for 12 hours daily. Current labs: blood glucose 412 mg/dL (22.9 mmol/L), potassium 4.2 mEq/L, and serum osmolality is elevated. Vital signs: heart rate 108/min, blood pressure 138/84 mm Hg, respirations 20/min, afebrile. Which lab value requires IMMEDIATE intervention for a client on TPN?
    Answer: Blood glucose 412 mg/dL (22.9 mmol/L) This question tests clinical judgment in TPN care and metabolic monitoring. The priority concern is hyperglycemia, a metabolic complication from high dextrose content in TPN. Blood glucose of 412 mg/dL requires immediate intervention as it can lead to osmotic diuresis, dehydration, and ketoacidosis if untreated. Potassium 4.2 mEq/L, sodium 140 mEq/L, and albumin 3.4 g/dL are within normal ranges and do not require urgent action, countering misconceptions that all lab values in TPN need equal priority. Prioritizing client safety involves frequent glucose monitoring and insulin adjustment. Decision-making in TPN care focuses on balancing nutritional needs with metabolic stability. A transferable nursing strategy is to monitor blood glucose every 4-6 hours initially and adjust TPN composition as needed to prevent hyperglycemia.
  15. A 62-year-old client with a history of type 2 diabetes and hypertension is postoperative day 2 after bowel resection for obstruction and is receiving total parenteral nutrition (TPN) via a peripherally inserted central catheter (PICC). The TPN is infusing continuously at 75 mL/hr and contains dextrose 20%, amino acids 5%, and electrolytes; 20% lipid emulsion is infused separately at 10 mL/hr for 12 hours daily. Current data: T 38.6°C (101.5°F), HR 112/min, BP 104/62 mm Hg, RR 20/min; the PICC insertion site is mildly erythematous with tenderness; blood glucose is 246 mg/dL. Which assessment finding indicates a complication of TPN therapy?
    Answer: Temperature 38.6°C (101.5°F) with PICC site erythema and tenderness This question tests TPN care and metabolic monitoring clinical judgment, specifically recognizing signs of catheter-related bloodstream infection. The priority concern is infection at the PICC site, evidenced by fever (38.6°C/101.5°F), erythema, and tenderness, which indicates a potentially life-threatening complication requiring immediate intervention. While hyperglycemia (246 mg/dL) is expected with TPN and requires monitoring, and tachycardia may be related to fever or postoperative status, the combination of fever with local signs at the catheter site represents the highest priority as it suggests catheter-related infection. The lipid infusion duration is appropriate and not a complication. The decision-making principle is that signs of infection in a client with a central line always take priority due to the risk of sepsis. The transferable nursing strategy is to assess central line sites systematically for signs of infection (redness, warmth, tenderness, drainage) with every shift and correlate with systemic signs like fever.
  16. A 59-year-old client with diabetes is receiving TPN after bowel surgery via central line. The current TPN contains dextrose 25%, amino acids 5%, electrolytes, vitamins at 85 mL/hr; regular insulin is added to the bag per order. The client's capillary blood glucose trends upward from 180 to 320 mg/dL (10.0 to 17.8 mmol/L) over 6 hours. What is the nurse's PRIORITY action for a client receiving TPN?
    Answer: Verify the infusion rate and implement the prescribed hyperglycemia management protocol (e.g., supplemental insulin) and notify the provider as indicated This question tests clinical judgment in TPN care and metabolic monitoring. The priority concern is hyperglycemia in diabetic clients on high-dextrose TPN. Verifying rate, implementing protocol, and notifying is the highest priority to manage rising glucose safely. Stopping TPN risks malnutrition; delegating rechecks delays; ambulation is insufficient, addressing misconceptions about non-pharmacologic control. Prioritizing client safety involves insulin protocols. Decision-making in TPN care emphasizes glucose trends. A transferable nursing strategy is to add insulin to TPN and monitor frequently in diabetics.
  17. A 9-year-old child with short bowel syndrome is receiving long-term TPN at home: 1,200 mL over 12 hours nightly (dextrose 15%, amino acids 3%, electrolytes, vitamins, trace elements) with 20% lipids 3 times per week. During a clinic visit, the child's weight has decreased by 1.5 kg (3.3 lb) in 1 month and height percentile has dropped; the caregiver reports the child "sometimes skips" the infusion on weekends. What is the nurse's PRIORITY action for a client receiving TPN?
    Answer: Assess adherence barriers and reinforce the prescribed infusion schedule to prevent malnutrition and growth failure The child's weight loss and falling height percentile, together with skipped weekend infusions, point to underdelivery of TPN. The nurse's first action is to explore why the prescribed schedule is not being followed and reinforce it, because untreated nonadherence leads to malnutrition and growth failure. Encouraging high-fiber foods does not replace TPN and may worsen short-bowel symptoms. Delegating a 6-month follow-up delays needed nutritional monitoring and never addresses the missed infusions. Requesting TPN discontinuation because the child is school-aged ignores the ongoing medical need; age is not a reason to stop therapy. The priority is to identify adherence barriers before making other plans.
  18. A 53-year-old client is postoperative after bowel surgery and receiving TPN via central line due to ileus. The TPN is infusing at 65 mL/hr (dextrose 20%, amino acids 5%, electrolytes, vitamins). The nurse receives a new order to abruptly discontinue TPN now that the client is tolerating clear liquids. The client's recent capillary blood glucose values have been 160–210 mg/dL (8.9–11.7 mmol/L). The nurse should QUESTION which TPN order?
    Answer: Abruptly discontinue TPN now that clear liquids are tolerated This question tests clinical judgment in TPN care and metabolic monitoring. The priority concern is rebound hypoglycemia from sudden TPN cessation. Abruptly discontinuing TPN should be questioned as it risks low glucose in clients with recent hyperglycemia. Advancing diet, continuing monitoring, and flushing lines are appropriate during transitions, countering misconceptions about rapid weaning. Prioritizing client safety involves gradual tapering. Decision-making in TPN care focuses on metabolic stability during discontinuation. A transferable nursing strategy is to reduce TPN rate over hours while advancing enteral intake to prevent hypoglycemia.
  19. A 44-year-old client with severe pancreatitis is receiving TPN via a central venous catheter at 85 mL/hr (dextrose 25%, amino acids 5%, electrolytes, vitamins, trace elements) and 20% lipids 250 mL over 12 hours. On day 10 of therapy, the client reports generalized itching and has mild jaundice; labs show total bilirubin 3.1 mg/dL (normal 0.2–1.2), alkaline phosphatase 210 U/L (normal 44–147), and AST/ALT mildly elevated. Which assessment finding indicates a complication of TPN therapy?
    Answer: Total bilirubin 3.1 mg/dL with new jaundice This question tests TPN care and metabolic monitoring clinical judgment, focusing on recognizing TPN-associated liver dysfunction. The priority concern is hepatic dysfunction evidenced by elevated bilirubin (3.1 mg/dL), jaundice, itching, and elevated liver enzymes after 10 days of TPN therapy, indicating TPN-associated cholestasis. While mild tachycardia after activity is expected, trace elements are necessary components of TPN, and glucose of 152 mg/dL is acceptable during stress, the liver dysfunction represents a serious complication requiring intervention. The decision-making principle is that new-onset jaundice and elevated liver enzymes in clients on long-term TPN indicate hepatic complications requiring evaluation and possible TPN modification. The transferable nursing strategy is to monitor liver function tests weekly in clients on TPN longer than 2 weeks and recognize that jaundice, itching, and elevated bilirubin suggest TPN-related cholestasis.
  20. A 5-year-old child with short bowel syndrome after necrotizing enterocolitis has a tunneled central line and receives TPN at home. Today the child is admitted for evaluation of poor growth; the caregiver reports the TPN runs overnight at 60 mL/hr for 12 hours and contains dextrose 17%, amino acids 4%, and 20% lipids 150 mL nightly. Assessment shows weight down 0.6 kg in 1 month, dry mucous membranes, and a capillary blood glucose of 58 mg/dL. What is the nurse's PRIORITY action for this child receiving TPN?
    Answer: Give a fast-acting carbohydrate per hypoglycemia protocol and recheck glucose This question tests TPN care and metabolic monitoring clinical judgment, focusing on recognizing and treating hypoglycemia in a pediatric client. The priority concern is hypoglycemia with a blood glucose of 58 mg/dL, which requires immediate intervention to prevent neurological complications in a young child. Giving a fast-acting carbohydrate per hypoglycemia protocol and rechecking glucose is the highest priority action to rapidly correct the dangerously low blood sugar. While insulin would worsen the hypoglycemia, obtaining a calorie count delays urgent treatment, and delegating central-line care is unrelated to the immediate problem. The decision-making principle is that hypoglycemia in children requires immediate treatment due to their higher metabolic demands and risk for neurological sequelae. The transferable nursing strategy is to recognize that pediatric clients on cycled TPN are at high risk for rebound hypoglycemia when TPN is discontinued and require close glucose monitoring.

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