In managing an 81-year-old patient with significant hyperglycemia and a history of chronic kidney disease, what should the NP administer first?

Administering insulin first in the management of a patient with significant hyperglycemia, especially in the context of chronic kidney disease and advanced age, is a critical and appropriate choice. Insulin can provide a rapid and effective means to lower blood glucose levels, which is essential in addressing hyperglycemia. Given the patient's age and underlying kidney function, they may be less tolerant of prolonged hyperglycemia, and immediate action is necessary to prevent complications such as diabetic ketoacidosis or hyperglycemic hyperosmolar state.

Moreover, the other options — metformin, sodium-glucose cotransporter-2 (SGLT2) inhibitors, and dipeptidyl peptidase-4 (DPP-4) inhibitors — may not be suitable for acute management in this scenario. Metformin, for instance, is generally contraindicated in cases of significant renal impairment due to an increased risk of lactic acidosis. SGLT2 inhibitors require sufficient kidney function to be effective and safe, and DPP-4 inhibitors, while potentially safer in terms of renal side effects, do not exert their action as rapidly as insulin.

Thus, the choice of insulin as the first-line agent effectively addresses the urgent need for glucose reduction in a vulnerable