Michael Jackson
A client with a diagnosis of type 2 diabetes has been ordered a course of prednisone for severe arthritic pain. Which expected change requires close monitoring by the nurse?
1.
Increased blood glucose level
2.
Increased platelet aggregation
3.
Increased creatinine clearance
4.
Decreased white blood cell (WBC) count
Correct Answer: 1
Rationale:
An adverse reaction to corticosteroids is hyperglycemia. A client with type 2 diabetes must monitor blood glucose levels closely while taking steroids. Creatinine clearance measures renal function. Platelet aggregation is associated with hematologic disorders. Clients taking corticosteroids are at increased risk for infection as a result of suppressed immune response, not a decrease in WBCs.
It is important for the nurse to teach the client which of the following about metformin?
1.
It may cause constipation.
2.
It should be taken at night.
3.
It should be taken with meals.
4.
It may increase the effects of aspirin.
Correct Answer: 3
Rationale:
Metformin is administered with meals to minimize gastrointestinal (GI) effects. These adverse effects are abdominal bloating, diarrhea, nausea, vomiting, and an unpleasant metallic taste. Metformin interacts with alcohol and cimetidine and is contraindicated in clients with compromised renal function, heart failure, and liver disease.
A client with diabetes receives a dose of NPH insulin at 7:00 am. The nurse teaches the client to be alert for signs of hypoglycemia at which times?
1.
From 12:00 pm to 1:00 pm
2.
9:00 am and 5:00 pm
3.
11:00 am and 4:00 pm
4.
8:00 am and 11:00 am
Correct Answer: 3
Rationale:
NPH (an intermediate-acting insulin) peaks in 4 to 10 hours. Hypoglycemia would most likely occur between 11:00 am and 4:00 pm.
WThe nurse is administering metformin to a client. Which observation indicates a therapeutic response to this medication?
1.
Blood sugar level maintained at 90 to 100 mg/dL (5.0 to 5.6 mmol/L)
2.
Decrease in the serum uric acid levels
3.
Urine output increased to 60 mL/hr
4.
BP increased to 120/80 mm Hg
Correct Answer: 1
Rationale:
Metformin is an oral antidiabetic medication in the biguanides category used for the control of adult-onset (type 2) diabetes. The desired response is a normal blood sugar level, which is 70 to 120 mg/dL (3.9 to 6.7 mmol/L).
Glipizide 10 mg bid (twice daily) po (by mouth) has been ordered for an adult client with type 2 diabetes. The nurse would explain to the client that the medication reduces the blood sugar level by what process?
1.
Delays the cellular uptake of potassium and insulin
2.
Stimulates insulin release from the pancreas
3.
Decreases the body's need for and utilization of insulin at the cellular level
4.
Interferes with the absorption and metabolism of fats and carbohydrates
Correct Answer: 2
Rationale:
The sulfonylureas (glipizide) reduce the blood glucose level by stimulating insulin release from the pancreas. Over a long period of time, sulfonylureas may actually increase insulin effects at the cellular level and decrease glucose production by the liver. This is the reason that sulfonylureas are prescribed for clients with type 2 diabetes who still have a functioning pancreas.
A client with diabetes receives 10 units of regular insulin at 6:00 am and does not eat breakfast. Around noon, what observation would the nurse expect to see?
1.
Polydipsia
2.
Polyphagia
3.
Polyuria
4.
Diaphoresis
Correct Answer: 4
Rationale:
The nurse would expect symptoms of hypoglycemia, which include diaphoresis, shakiness, fatigue, hunger, and low blood sugar. The three Ps—polydipsia, polyphagia, and polyuria—are observed in hyperglycemia.
Which statement describes correct administration of insulin lispro?
1.
It needs to be taken after meals.
2.
It should be taken within 15 minutes of beginning a meal.
3.
It is to be taken once daily at the noon meal.
4.
It is taken only in the evenings with a snack before bedtime.
Correct Answer: 2
Rationale:
Rapid-acting insulins, such as insulin lispro and insulin aspart, can more closely mimic the body's natural rapid insulin output after consumption of a meal, which is why both medications usually are administered within 15 minutes before or after a meal. (Lehne, 8 ed., p. 712.)
What would be important for the nurse to include in the teaching plan for a client who is taking insulin?
1.
The client should use only the injection sites that are most accessible.
2.
During times of illness, clients should increase their insulin dosage by 25%.
3.
When mixing insulins, the NPH insulin should be drawn up into the syringe first.
4.
When mixing insulins, regular insulin should be drawn up into the syringe first.
Correct Answer: 4
Rationale:
If mixing insulins, the regular insulin should always be drawn up into the syringe first. Remember, clear to cloudy: regular insulin first, followed by cloudy ones, such as NPH and Ultralente. Clients should always rotate injection sites (preferably in the abdomen) and should notify their physicians if they become ill.
The nurse is teaching the parents of a child who is experiencing difficulty with control of his diabetes. Which agent should the nurse teach the parents to administer if their child loses consciousness and has a severe hypoglycemic reaction?
1.
IV dextrose
2.
SubQ insulin
3.
SubQ glucagon
4.
Oral fast-acting carbohydrate
Correct Answer: 3
Rationale:
If the child has a severe hypoglycemic episode, he frequently is neurologically compromised. It is important to administer subQ or IM glucagon. SubQ insulin would further worsen the child's condition. IV dextrose would be given in the hospital. Oral administration of fast-acting carbohydrates is reserved for the conscious child who is not having a severe hypoglycemic reaction.
An 8-year-old boy with type 1 diabetes has been receiving NPH and regular insulin. His mother calls the nurse and explains that the child's morning blood glucose readings have been above 200 mg/dL (11.1 mmol/L). What should the nurse advise the mother to do?
1.
Raise his NPH dose by two units to cover the elevation in the early morning.
2.
Change the time of the night dose to 1 hour before sleep.
3.
Do blood glucose checks during the night.
4.
Keep a glass of water near the bed to dilute the sugar levels during the night.
Correct Answer: 3
Rationale:
The child is having a rapid decrease in his blood glucose level during the night, causing a hyperglycemic rebound response. The rebound rise in the blood sugar reading is picked up in the morning blood glucose reading, which can lead to misinterpretation. This may be classified as a Somogyi effect.
A client with type 1 diabetes calls the nurse because of nausea and not feeling well. What would be important for the nurse to tell the client?
1.
"Hold the oral hypoglycemics until you can begin eating again."
2.
"Take the insulin as scheduled, increase water intake, and continue to monitor your blood glucose."
3.
"Take your regular dose of insulin, replace food with fruit juices, and monitor your blood glucose."
4.
"Do not take any insulin as long as you are nauseous and cannot maintain intake."
Correct Answer: 3
Rationale:
This client is on insulin for diabetic control. He or she should continue taking the regularly scheduled dose of insulin and eating the prescribed diet, as well as increasing the amount of low-calorie fluids (e.g., broth, water, decaffeinated tea). If the client is unable to consume solid foods or keep food down, then caloric intake can be increased by drinking carbohydrate fluids (e.g., juices and soups). It is important for the client to check his or her blood glucose levels every 4 hours. Additionally, for the type 1 diabetic client with blood glucose levels greater than 240 mg/dL, urine testing for ketones every 3 to 4 hours is required, and findings should be reported to the health care provider. The blood sugar may continue to rise because of the illness, which is why it is important to continue medication.
The nurse is caring for a client in diabetic ketoacidosis (DKA). An order exists for insulin to be added to the current infusing IV. What type of insulin will the nurse use?
1.
Insulin detemir
2.
Regular insulin
3.
NPH insulin
4.
Insulin glargine
Correct Answer: 2
Rationale:
Regular insulin and the rapid acting insulins (i.e., insulin lispro, insulin aspart, and insulin glulisine) are the only forms of insulin recommended for IV use. The rapid- and slower-acting insulins are clear. All the other insulins are for subQ injection or are cloudy.
A client is found to be comatose and hypoglycemic with a blood glucose level of 50 mg/dL (2.8 mmol/L). What nursing action is implemented first?
1.
Infuse 1000 mL of D5W over a 12-hour period.
2.
Administer 50% intravenous (IV) glucose.
3.
Check the client's urine for the presence of sugar and acetone.
4.
Encourage the client to drink orange juice with added sugar
Correct Answer: 2
Rationale:
The unconscious, hypoglycemic client needs immediate treatment with 50% IV glucose (highly concentrated). Administering 1000 mL of D5W over 12 hours does not provide enough glucose to treat the problem. Trying to give oral fluids to an unconscious client should never be done because it increases the risk for aspiration. Urine sugar does not need to be evaluated if the serum blood glucose is available.
A client with diabetes asks the nurse about the A1C test. What is the nurse's best response regarding the purpose of this test?
1.
"It determines how close the client is to having an insulin reaction."
2.
"It reflects blood glucose control for 3 months before the current status."
3.
"It determines how much glucose is excreted over a 24-hour control period."
4.
"It helps determine the amount of retinopathy the client is experiencing."
Correct Answer: 2
Rationale:
The A1C test provides information regarding the client's control of blood sugar for about 120 days or 3 months. This is beneficial for clients who experience fluctuations in control. It measures the reaction when the glucose combines with the hemoglobin molecule and is indicative of the general blood sugar control the client has had over the previous 3 to 4 months. It is not influenced by the type of treatment, the current level of blood sugar, or the client's intake over the past several hours. An A1C of more than 6.5% indicates an increased risk of microvascular disease such as retinopathy.
The nurse is assessing an 80-year-old client with type 2 diabetes. The assessment findings include rapid, deep, respirations at a rate of 36 breaths/min. Lethargy and tachycardia are present. What would the symptoms most indicate?
1.
Hyponatremia
2.
Hypoglycemia
3.
Diabetic ketoaidosis (DKA)
4.
Hyperglycemic hyperosmolar syndrome (HHS)
Correct Answer: 4
Rationale:
Kussmaul respirations, which are deep, regular, sighing respirations with tachypnea, along with the presence of tachycardia and CNS symptoms (lethargy) correlate with hyperglycemia. Because of the client's age, the problem would most likely be HHS (formerly known as hyperglycemic-hyperosmolar nonketotic syndrome [HHNS]). DKA occurs most often in younger clients with type 1 diabetes. Hypoglycemia is a low blood glucose level. In DKA and in HHS, the blood glucose level is greater than 300 mg/dL (16.7 mmol/L). The sodium levels may be high, low, or normal.
A client newly diagnosed with type 1 diabetes mellitus is learning about diabetic foot care. What will the nurse instruct the client to avoid?
1.
Emollient lotions
2.
Foot powder
3.
Foot soaks
4.
Nail files
Correct Answer: 3
Rationale:
Foot soaks macerate the skin and can increase the risk of breaks in the skin. Water-soluble lotions are recommended to moisturize the feet. Nail files are preferred over nail clippers or scissors. Foot powder may be used when foot perspiration exists.
A client with type 2 diabetes is going to have major abdominal surgery. How will the nurse anticipate controlling blood sugar levels in this client during the immediate postoperative period?
1.
Keeping the client NPO until blood sugar levels are stable
2.
Daily administration of oral hypoglycemics
3.
A 1500-calorie diet as soon as tolerated
4.
Insulin on a sliding scale basis
Correct Answer: 4
Rationale:
In the first few hours and/or days after surgery, blood sugar frequently fluctuates. Even though the client has type 2 diabetes, insulin is often used to control the blood sugar in the first few post operative days. Oral hypoglycemics do not provide a predictable, even control of blood sugar. Dietary control and reestablishment of oral hypoglycemics will begin during the client's recovery phase.
A client with diabetes mellitus calls the office nurse to review insulin administration sick day rules. Which statement indicates a need for further instruction?
1.
"I will hold my insulin if I am feeling sick."
2.
"I should call the office if I am sick more than 2 days."
3.
"If I am sick, I will check my blood glucose every 4 hours."
4.
"When not feeling well, I should increase my intake of fluids.
Correct Answer: 1
Rationale:
Insulin should be taken consistently especially when sick. The stress response created by illness can make the blood sugar increase. Checking blood sugar more frequently is recommended. Fluids are recommended. If the sugar is running low, then fluids with sugar are recommended. If the blood sugar is running high, then fluids without sugar are recommended. Illnesses lasting longer than 2 days should be investigated.
What is the primary action of insulin in the body?
1.
Enhances the transport of glucose across cell walls
2.
Aids in the process of gluconeogenesis
3.
Stimulates the pancreatic beta cells
4.
Decreases the intestinal absorption of glucose
Correct Answer: 1
Rationale:
Insulin acts to lower the blood sugar level, primarily by improving the transport of glucose into the cells. It is the principal regulator of the metabolism and storage of fats, carbohydrates, and proteins. It is a hormone produced in the beta cells in the islets of Langerhans of the pancreas. The rise in insulin after a meal stimulates the conversion of glucose to glycogen, inhibits gluconeogenesis, enhances fat deposition, and increases protein synthesis. It does not decrease intestinal absorption of glucose but works in the bloodstream to promote glucose transport across the cell membrane to the cytoplasm of the cell.
A nurse is caring for a client with type 1 diabetes mellitus. With a blood glucose level of 200 mg/dL (11.1 mmol/L), how many units of regular insulin will the nurse administer according to the sliding scale?
1.
Blood glucose at 200 mg/dL (11.1 mmol/L) or less = no insulin
2.
Blood glucose at 201 to 229 mg/dL (11.2 to 12.7 mmol/L) = 2 units of insulin
3.
Blood glucose at 230 to 259 mg/dL (12.8 to 14.4 mmol/L) = 4 units of insulin
4.
Blood glucose at 260 to 300 mg/dL (14.5 to 16.7 mmol/L) = 6 units of insulin
Correct Answer: 1
Rationale:
With the blood sugar level at 200 mg/dL (11.1 mmol/L), no additional regular insulin must be given. Sliding scale insulin dosage is determined by the amount of glucose in the blood, which is based on glucometer readings. The sliding scale enables the client to receive appropriate amounts of insulin as the blood glucose level fluctuates throughout a 24-hour period.
Why does hyperglycemia occur in a client with type 2 diabetes mellitus? Select all that apply.
1.
Insulin resistance
2.
Insulin deficiency
3.
Gestational diabetes
4.
Liver dysfunction
5.
Hyperinsulinemia
6.
Alpha cell dysfunction
Correct Answer(s): 1,2,4
Rationale:
Type 2 diabetes mellitus is due to insulin resistance, insulin deficiency, and inappropriate glucose production by the liver. Beta cells in the pancreas increase production for a period of time; then they can no longer compensate. Insulin resistance and secondary failure of the pancreas to secrete enough insulin result in hyperglycemia, even though the cells receive inadequate amounts of glucose.
"Why did the doctor tell me I may not know when my blood sugar is low? "Which response is most accurate?
1.
"When you drink alcohol, you are less likely to have a diabetic reaction."
2.
"The medication for your heart can hide the symptoms of hypoglycemia."
3.
"Younger adults are less likely to experience diaphoresis with hypoglycemia."
4.
"Because you are older, we want to keep your blood glucose in tight control."
Correct Answer: 2
Rationale:
Older adults and clients using beta-adrenergic blockers (atenolol, propranolol) are less likely to experience early signs of hypoglycemia. No indication is given that the client is using alcohol. Younger adults should experience symptoms of hypoglycemia unless they are using a beta-adrenergic blocker.
An insulin-dependent client wakes up at 3:00 am and calls the nurse complaining of slight headache, nausea, and trembling. While the nurse assesses the client, she notices that his extremities are cool and moist. What would be a priority nursing intervention?
1.
Call the laboratory for a stat blood glucose.
2.
Administer acetaminophen and aprepitant.
3.
Have the client drink a glass of orange juice.
4.
Use a glucometer to obtain a capillary blood glucose.
Correct Answer: 4
Rationale:
The client's symptoms indicate hypoglycemia and should be confirmed with a quick bedside glucometer test. Because the client is insulin dependent, the blood glucose should be assessed initially in the most expedient manner (i.e., bedside glucometer). When the blood sugar value is known, the nurse could offer orange juice. It is not necessary to administer medications such as acetaminophen and aprepitant because the pain and nausea should subside after the blood sugar is increased to normal levels.
A client with diabetes mellitus is self-monitoring glucose levels. The nurse explains to the client that it is important to maintain blood glucose levels no lower than about 60 mg/dL (3.3 mmol/L). What is the rationale for this explanation?
1.
Effective glucose levels prevent lactic acid buildup and metabolic acidosis.
2.
The rise in plasma insulin after a meal stimulates storage of glucose as glycogen.
3.
High glucose levels promote the conversion of the excess glucose into fatty acids.
4.
The brain cannot store glucose, so it needs a constant supply from a normal glucose level.
Correct Answer: 4
Rationale:
There needs to be a constant blood glucose level in the range of 60 to 100 mg/dL (3.3 to 5.6 mmol/L) to support brain function, because the brain cannot store glucose as the liver does. This continuous supply of glucose from the circulation is important in preventing neuron dysfunction and brain cell death. The other options are true statements, but do not address what the question is asking.
A client with diabetes mellitus wants to use an insulin pump rather than giving injections. Which client statement indicates a need for further instruction?
1.
"I will change the insertion site every two to three days."
2.
"Long acting and short acting insulin are loaded into the insulin pump."
3.
"The catheter insertion site should be monitored for redness and swelling."
4.
"The insulin pump can give a bolus dose to cover an elevated blood sugar."
Correct Answer: 2
Rationale:
Insulin pumps are filled with rapid acting insulin administered at a basal dose. Bolus doses are programmed based on carbohydrate intake. Catheter sites are changed every two to three days. At the same time, the insulin is replenished. Some devices may include a continuous blood sugar monitoring system with wireless data transmission. The sites should be monitored for redness and swelling.