Care of Patients with Diabetes Mellitus

41. A client with type 1 diabetes has a blood glucose level of 160 mg/dL on arrival at the operating room. Which is the nurse's best action? a. Document the finding in the client's chart. b. Administer a bolus of regular insulin IV. c. Call the physician to cancel the operation. d. Draw blood gases to assess the metabolic state.

ANS: A Clients who have type 1 diabetes and are having surgery have been found to have fewer complications, lower rates of infection, and better wound healing if blood glucose levels are maintained at between 140 and 180 mg/dL throughout the perioperative period. The nurse should document the finding and proceed with other operative care. The need for a bolus of insulin, for canceling the operation, or for drawing arterial blood gases (ABGs) is not present.

28. To reduce complications of diabetes, the nurse teaches a client with normal kidney function to modify intake of which nutritional group? a. Fats b. Fiber c. Proteins d. Carbohydrates

ANS: A Diabetes causes abnormalities in fat metabolism that lead to hyperlipidemia. The high lipid levels can lead to atherosclerosis and to many pathologic consequences of vascular insufficiency. Specific fat recommendations can be made by the registered dietitian according to individual client factors, but reducing fat intake is healthy for all diabetic people. The client with renal insufficiency may need to limit protein. Fiber should be increased do 25 to 30 g/day, and intake of carbohydrates must be spread out throughout the day.

9. A client has newly diagnosed diabetes. To delay the onset of microvascular and macrovascular complications in this client, the nurse stresses that the client take which action? a. Control hyperglycemia. b. Prevent hypoglycemia. c. Restrict fluid intake. d. Prevent ketosis.

ANS: A Hyperglycemia is a critical factor in the pathogenesis of long-term diabetic complications. Maintaining tight glycemic control will help delay the onset of complications. Preventing hypoglycemia and ketosis, although important, is not as important as maintaining daily glycemic control. Restricting fluid intake is not part of the treatment plan for clients with diabetes.

38. Which statement made by a client getting ready for discharge after pancreas transplantation indicates a need for further teaching about the prescribed drug regimen? a. "If I develop an infection, I should stop taking my corticosteroid." b. "If I have pain over the transplant, I will call the surgeon immediately." c. "I should avoid people who are ill or who have an infection." d. "I should take my cyclosporine exactly the way I was taught."

ANS: A Immune suppressive agents should not be stopped without the consultation of the transplantation physician, even if an infection is present. Stopping immune suppressive therapy endangers the transplanted organ. The other statements are correct. Pain over the graft site may indicate rejection. Anti-rejection drugs cause immune suppression, and the client should avoid crowds and people who are ill. Changing the routine of anti-rejection medications may cause them to not work optimally.

20. A client with diabetes is prescribed insulin glargine once daily and regular insulin four times daily. One dose of regular insulin is scheduled at the same time as the glargine. How does the nurse instruct the client to administer the two doses of insulin? a. "Draw up and inject the insulin glargine first, then draw up and inject the regular insulin." b. "Draw up and inject the insulin glargine first, wait 20 minutes, then draw up and inject the regular insulin." c. "First draw up the dose of regular insulin, then draw up the dose of insulin glargine in the same syringe, mix, and inject the two insulins together." d. "First draw up the dose of insulin glargine, then draw up the dose of regular insulin in the same syringe, mix, and inject the two insulins together."

ANS: A Insulin glargine must not be diluted or mixed with any other insulin or solution. Mixing results in an unpredictable alteration in the onset of action and time to peak action. The correct instruction is to draw up and inject first the glargine, then the regular insulin right afterward.

22. A client with diabetes is visually impaired and wants to know whether syringes can be prefilled and stored for later use. Which is the nurse's best response? a. "Yes. Prefilled syringes can be stored for 3 weeks in the refrigerator in a vertical position with the needle pointing up." b. "Yes. Prefilled syringes can be stored for up to 3 weeks in the refrigerator, placed in a horizontal position." c. "Insulin reacts with plastic, so prefilled syringes are okay, but they must be made of glass." d. "No. Insulin cannot be stored for any length of time outside of the container."

ANS: A Insulin is relatively stable when stored in a cool, dry place away from light. When refrigerated, prefilled syringes are stable for up to 3 weeks. They should be stored in the vertical position with the needle pointing up to prevent suspended insulin particles from clogging the needle. The other answers are inaccurate.

30. A client in the emergency department has been diagnosed with ketoacidosis. Which manifestation does the nurse correlate with this condition? a. Increased rate and depth of respiration b. Extremity tremors followed by seizure activity c. Oral temperature of 102° F (38.9° C) d. Severe orthostatic hypotension

ANS: A Ketoacidosis decreases the pH of the blood, stimulating the respiratory control areas of the brain to buffer the effects of increasing acidosis. The rate and depth of respiration are increased (Kussmaul respirations) in an attempt to excrete more acids by exhalation.

8. A client's father has type 1 diabetes mellitus. The client asks if she is in danger of developing the disease as well. Which is the nurse's best response? a. "Your risk of diabetes is higher than that of the general population, but it may not occur." b. "No genetic risk is associated with the development of type 1 diabetes." c. "The risk for becoming diabetic is 50% because of how it is inherited." d. "Female children do not inherit diabetes, but male children will."

ANS: A Risk for type 1 diabetes is determined by inheritance of genes coding for HLA-DR and HLA-DQ tissue types. Clients who have one parent with type 1 diabetes are at increased risk for its development. Diabetes (type 1) seems to require interaction between inherited risk and environmental factors, so not everyone with these genes develops diabetes. The other statements are not accurate.

18. A client has been taught to inject insulin. Which statement made by the client indicates a need for further teaching? a. "The abdominal site is best because it is closest to the pancreas." b. "I can reach my thigh the best, so I will use different areas of the same thigh." c. "By rotating the sites in one area, my chance of having a reaction is decreased." d. "Changing injection sites from the thigh to the arm will change absorption rates."

ANS: A The abdominal site has the fastest rate of absorption because of blood vessels in the area, not because of its proximity to the pancreas. The other statements are accurate assessments of insulin administration.

16. A client who has been taking pioglitazone (Actos) for 6 months reports to the nurse that his urine has become darker since starting the medication. Which is the nurse's first action? a. Review results of liver enzyme studies. b. Document the report in the client's chart. c. Instruct the client to increase water intake. d. Test a sample of urine for occult blood.

ANS: A Thiazolidinediones (including pioglitazone) can affect liver function; liver function should be assessed at the start of therapy and at regular intervals while the client continues to take these drugs. Dark urine is one indicator of liver impairment because bilirubin is increased in the blood and is excreted in the urine. The nurse should check the client's most recent liver function studies. Documentation should be done after all assessments have been completed. The client does not need to be told to increase water intake, and the nurse does not need to check the urine for occult blood.

47. The home care nurse finds a client who has diabetes awake and alert, but shaky, diaphoretic, and weak. The nurse gives the client cup of orange juice. The client's clinical manifestations have not changed 5 minutes later. Which is the nurse's best next action? a. Give the client another cup of orange juice. b. Call the rescue squad for transportation to the hospital. c. Administer 10 units of regular insulin subcutaneously. d. Administer 1 mg glucagon intramuscularly.

ANS: A This client is experiencing mild hypoglycemia. For mild hypoglycemic manifestations, if the symptoms do not resolve immediately, repeat the treatment. The client does not need glucagon, transportation to the hospital, or insulin.

12. A client with diabetes has frequent blood glucose readings higher than 300 mg/dL. Which action does the nurse teach the client about self-care? a. Check urine ketones when blood glucose readings are high. b. Increase the insulin dose after two high glucose readings in a row. c. Change the diet to include a 10% increase in protein. d. Work out on the treadmill whenever glucose readings are high.

ANS: A Urine should be tested for ketone bodies whenever the client has a blood glucose higher than 300 mg/dL; is acutely ill, under stress, pregnant, or participating in a weight reduction program; or has symptoms of ketoacidosis (nausea, vomiting, and abdominal pain). The client should not change diet and insulin dosages without input from the health care provider. The client should not exercise when blood glucose is higher than 250 mg/dL.

1. The nurse is performing health screening in a local mall. Which people does the nurse counsel to be tested for diabetes? (Select all that apply.) a. African-American or American Indian b. Person with history of pancreatic trauma c. Woman with a 30-pound weight gain during pregnancy d. Male with a body mass index greater than 25 kg/m2 e. Middle-aged woman with physical inactivity most days of the week f. Young woman who gave birth to a baby weighing more than 9 pounds

ANS: A, D, E, F Risk factors for type 2 diabetes include certain ethnic/racial groups (African Americans, American Indians, Hispanics), obesity and physical inactivity, and giving birth to large babies. Pancreatic trauma and a 30-pound gestational weight gain are not risk factors.

2. A client with diabetes asks the nurse why it is necessary to maintain blood glucose levels no lower than about 60 mg/dL. Which is the nurse's best response? a. "Glucose is the only fuel used by the body to produce the energy that it needs." b. "Your brain needs a constant supply of glucose because it cannot store it." c. "Without a minimum level of glucose, your body does not make red blood cells." d. "Glucose in the blood prevents the formation of lactic acid and prevents acidosis."

ANS: B Because the brain cannot synthesize or store significant amounts of glucose, a continuous supply from the body's circulation is needed to meet the fuel demands of the central nervous system. The other statements are not accurate.

36. The nurse is teaching a client with diabetes about exercise. Which statement by the client indicates a need for further teaching? a. "I won't exercise if I find ketones in my urine." b. "If my blood glucose is over 200, I should not exercise." c. "Exercise will help me keep my blood glucose down." d. "My risks for heart disease can be modified with exercise."

ANS: B Clients should not exercise if their blood glucose is over 250 mg/dL. The other statements are correct and show good understanding.

57. Which statement by a client with type 2 diabetes indicates a need for further teaching about diabetic management and follow-up care? a. "I need to have an annual appointment, even if my glucose levels are in good control." b. "Because my diabetes is controlled with diet and exercise, I have to be seen only if I am sick." c. "I can still develop complications, even though I do not have to take insulin at this time." d. "If I have surgery or get very ill, I may have to receive insulin injections for a short time."

ANS: B Clients with diabetes need to be seen at least annually to monitor for long-term complications, including visual changes, microalbuminuria, and lipid analysis. The other statements are correct.

43. A client with a 20-year history of diabetes mellitus is reviewing his medications with the nurse. The client holds up the bottle of duloxetine (Cymbalta) and states, "My cousin has depression and is on this drug. Do you think I'm depressed?" What is the nurse's best response? a. "Many people with long-term diabetes become depressed after a while." b. "It's for peripheral neuropathy. Do you have burning pain in your feet or hands?" c. "This antidepressant also has anti-inflammatory properties for diabetic pain." d. "That is possible, but most medications are used for several different things."

ANS: B Damage along nerves causes peripheral neuropathy and leads to burning pain along the nerves. Many drugs, including duloxetine (Cymbalta), can be used to treat peripheral neuropathy. The nurse should assess the client for this condition and then should provide an explanation of why this drug is being used. This medication, although it is used for depression, is not being used for that reason in this case. Cymbalta does not have anti-inflammatory properties. The last option does not provide the client with enough information to be useful.

17. A client with diabetes asks why more than one injection of insulin is required each day. Which is the nurse's best response? a. "You need to start with multiple injections until you become more proficient at self-injection." b. "A single dose of insulin each day would not match your blood insulin levels and your food intake patterns closely enough." c. "A regimen of a single dose of insulin injected each day would require that you could eat no more than one meal each day." d. "A single dose of insulin would be too large to be absorbed predictably, so you would be in danger of unexpected insulin shock."

ANS: B Even when a single injection of insulin contains a combined dose of different-acting insulins, the timing of the actions and the timing of food intake may not match well enough to prevent wide variations in blood glucose levels.

48. The nurse has given a client an injection of glucagon. Which action does the nurse take next? a. Apply pressure to the injection site. b. Position the client on his or her side. c. Have a padded tongue blade available. d. Elevate the head of the bed.

ANS: B Glucagon administration often induces vomiting, increasing the client's risk for aspiration. The other actions are not required.

14. The client with type 2 diabetes has recently been changed from the oral antidiabetic agents glyburide (Micronase) and metformin (Glucophage) to glyburide-metformin (Glucovance). The nurse includes which information in the teaching about this medication? a. "Glucovance is more effective than glyburide and metformin." b. "Glucovance contains a combination of glyburide and metformin." c. "Glucovance is a new oral insulin and replaces all other oral antidiabetic agents." d. "Your diabetes is improving and you now need only one drug."

ANS: B Glucovance is composed of glyburide and metformin. It is given to enhance the convenience of antidiabetic therapy with glyburide and metformin. The other statements are not accurate.

25. A client newly diagnosed with type 2 diabetes tells the nurse that since increasing fiber intake, he is having loose stools, flatulence, and abdominal cramping. Which is the nurse's best response? a. "Decrease your intake of water and other fluids until your stools firm up." b. "Decrease your intake of fiber now and gradually add it back into your diet." c. "You must have allergies to high-fiber foods and will need to avoid them." d. "Taking an antacid 1 hour before or 2 hours after meals will help this problem."

ANS: B Many people experience these side effects when first increasing dietary fiber. Gradually incorporating high-fiber foods into the diet can minimize abdominal cramping, discomfort, loose stools, and flatulence. The client needs increased water intake with fiber. The client does not have allergies, nor should he or she take antacids in the hope that they will reduce the problem.

39. The nurse correlates which laboratory value with inadequate functioning of a transplanted pancreas? a. Total white blood cell count 5000/mm3 b. 50% decrease in urine amylase level c. Blood urea nitrogen 30 mg/dL d. Elevated bilirubin level

ANS: B Most pancreas transplants are anastomosed to the bladder and drain pancreatic enzymes into the urine. When the pancreas is rejected or is functioning inadequately, the level of pancreatic enzymes in the urine decreases. The other options are not indicative of inadequate pancreatic function.

53. The nurse administers 6 units of regular insulin and 10 units NPH insulin at 7 AM. At what time does the nurse assess the client for problems related to the NPH insulin? a. 8 AM b. 4 PM c. 8 PM d. 11 PM

ANS: B NPH is an intermediate-acting insulin with an onset of 1.5 hours, peak of 4 to 12 hours, and duration of action of 22 hours. Checking the client at 8:00 AM would be too soon; 8:00 PM and 11:00 PM would be too late.

15. Which statement made by a client with type 2 diabetes taking nateglinide (Starlix) indicates understanding of this therapy? a. "I'll take this medicine with my meals." b. "I'll take this medicine right before I eat." c. "I'll take this medicine just before I go to bed." d. "I'll take this medicine when I wake up in the morning."

ANS: B Nateglinide is an insulin secretagogue that is designed to increase meal-related insulin secretion. It should be taken just before a meal. The other options are incorrect.

13. A client who has type 2 diabetes is prescribed glipizide (Glucotrol). Which precautions does the nurse include in the teaching plan related to this medication? a. "Change positions slowly when you get up." b. "Avoid taking nonsteroidal anti-inflammatory drugs." c. "If you miss a dose of this drug, you can double the next dose." d. "Discontinue the medication if you develop an infection."

ANS: B Nonsteroidal anti-inflammatory drugs potentiate the hypoglycemic effects of sulfonylurea agents. Glipizide is a sulfonylurea. The other statements are not applicable to glipizide.

34. The home care nurse visits an older client with diabetes. For which nutritional problem does the nurse monitor this client? a. Obesity b. Malnutrition c. Alcoholism d. Hyperglycemia

ANS: B Older adults are more at risk for developing malnutrition as a result of multiple factors. Inadequate income, poor dentition, decreased cognition, decreased motor ability, depression, and lack of understanding about which foods constitute an adequate diet all contribute to an increased risk for malnutrition in all older adult clients, including those with diabetes mellitus.

45. A client with a history of diabetes mellitus has new onset of microalbuminuria. Which component of the diet must the client reduce? a. Percentage of total calories derived from carbohydrates b. Percentage of total calories derived from proteins c. Percentage of total calories derived from fats d. Total caloric intake

ANS: B Restriction of dietary protein to 0.8 g/kg body weight/day is recommended for clients with microalbuminuria to retard progression to renal failure. The other options would not be needed.

11. The nurse is teaching a client about self-monitoring of blood glucose levels. To prevent bloodborne infection, which statement by the nurse is best? a. "Wash your hands after completing the test." b. "Do not share your monitoring equipment." c. "Blot excess blood from the strip." d. "Use gloves during monitoring."

ANS: B Small particles of blood can adhere to the monitoring device, and infection can be transported from one user to another. Hepatitis B in particular can survive in a dried state for about a week. The client should be taught to avoid sharing any equipment, including the lancet holder. The client should be taught to wash hands before testing. The client would not need to blot excess blood away from the strip or to wear gloves.

59. The nurse is caring for a critically ill client who has diabetic ketoacidosis (DKA). The nurse finds the following assessment data: blood pressure, 90/62; pulse, 120 beats/min; respirations, 28 breaths/min; urine output, 20 mL/1 hour per catheter; serum potassium, 2.6 mEq/L. The health care provider orders a 40 mEq potassium bolus and an increase in the IV flow rate. Which action by the nurse is most appropriate? a. Give the potassium after increasing the IV flow rate. b. Increase the IV rate; consult the provider about the potassium. c. Increase the IV rate; hold the potassium for now. d. Infuse the potassium first before increasing the IV flow rate.

ANS: B The client is acutely ill and is severely dehydrated and hypokalemic. The client requires more IV fluids and potassium. However, potassium should not be infused unless the urine output is at least 30 mL/hr. The nurse should first increase the IV rate, then consult with the provider about the potassium. The nurse should not just hold the potassium without consulting the provider because the client's level is dangerously low.

26. The nurse has been reviewing options for insulin therapy with several clients. For which client does the nurse choose to recommend the pen-type injector insulin delivery system? a. Older adult client who lives at home alone but has periods of confusion b. Client on an intensive regimen with frequent, small insulin doses c. Client from the low-vision clinic who has trouble seeing the syringe d. "Brittle" client who has frequent episodes of hypoglycemia

ANS: B The pen-type injector allows greater accuracy with small doses, especially doses lower than 5 units. It is not recommended for those who have visual or neurologic impairments. The client with frequent hypoglycemia would not derive special benefit from using the pen.

56. A client has been taught about lifestyle changes to help manage newly diagnosed diabetes mellitus type 2. Which statement by the client indicates good understanding? a. "Weight gain may lead to type 1 diabetes and I would need insulin." b. "I may not need to take medications if my weight is maintained." c. "I do not have to check my blood glucose if my weight is in the proper range." d. "My vision and foot pain may go away if I lose some weight."

ANS: B Type 2 diabetes can be prevented or delayed by weight loss and increased physical activity. Encourage all clients to maintain weight within an appropriate range for height and body build. Once diagnosed with type 2 diabetes, blood glucose monitoring is indicated, regardless of whether the client is taking oral antidiabetic medications. Vision and neurologic changes will not go away with weight control.

31. The nurse determines that which arterial blood gas values are consistent with ketoacidosis in the client with diabetes? a. pH 7.38, HCO3- 22 mEq/L, PCO2 38 mm Hg, PO2 98 mm Hg b. pH 7.28, HCO3- 18 mEq/L, PCO2 28 mm Hg, PO2 98 mm Hg c. pH 7.48, HCO3- 28 mEq/L, PCO2 38 mm Hg, PO2 98 mm Hg d. pH 7.28, HCO3- 22 mEq/L, PCO2 58 mm Hg, PO2 88 mm Hg

ANS: B When the lungs can no longer offset acidosis, the pH decreases to below normal. The arterial blood gases show primary metabolic acidosis with decreased bicarbonate levels and a compensatory respiratory alkalosis with decreased carbon dioxide levels.

52. A client is being treated for hyperglycemic-hyperosmolar state (HHS). Which clinical manifestation indicates to the nurse that the therapy needs to be adjusted? a. Serum potassium level has increased from 2.8 to 3.2 mEq/L. b. Blood osmolarity has decreased from 350 to 330 mOsm. c. Score on the Glasgow Coma Scale is unchanged from 3 hours ago. d. Urine has remained negative for ketone bodies for the past 3 hours.

ANS: C A slow but steady improvement in central nervous system (CNS) functioning is the best indicator of therapy effectiveness for HHS. Lack of improvement in level of consciousness may indicate inadequate rates of fluid replacement. The other assessment findings do not indicate adequacy of treatment.

37. Two months after a simultaneous pancreas-kidney (SPK) transplantation, a client is diagnosed as being in acute rejection. The client states, "I was doing so well with my new organs, and the thought of having to go back to living on hemodialysis and taking insulin is so depressing." Which is the nurse's best response? a. "You should have followed your drug regimen better." b. "You should be glad that at least dialysis treatment is an option for you." c. "One acute rejection episode does not mean that you will lose the new organs." d. "Our center is high on the list for obtaining organs from the national registry."

ANS: C An episode of acute rejection does not automatically mean that the client will lose the transplant. Pharmacologic manipulation of host immune responses at this time can limit damage to the organ and allow the graft to be maintained. The other statements either belittle the client or downplay his or her concerns.

46. Which statement made by a diabetic client who has a urinary tract infection indicates that teaching was effective regarding antibiotic therapy? a. "If my temperature is normal for 3 days in a row, I can stop taking my medicine." b. "If my temperature goes above 100° F (37.8° C), I should double the dose." c. "Even if I feel completely well, I should take the medication until it is gone." d. "When my urine no longer burns, I will no longer need to take the antibiotics."

ANS: C Antibiotic therapy is most effective when the client takes the prescribed medication for the entire course, not just when symptoms are present. The other statements are inaccurate.

24. A client has been newly diagnosed with diabetes mellitus. Which statement made by the client indicates a need for further teaching regarding nutrition therapy? a. "I should be sure to eat moderate to high amounts of fiber." b. "Saturated fats should make up no more than 7% of my total calorie intake." c. "I should try to keep my diet free from carbohydrates." d. "My intake of plain water each day is not restricted."

ANS: C Carbohydrates are an extremely important source of energy. They should compose at least 45% to 65% of the diabetic person's total caloric intake. The client needs to eat at least 130 g of carbohydrates a day. The other statements show good understanding.

55. A client was admitted with diabetic ketoacidosis (DKA). Which manifestations does the nurse monitor the client most closely for? a. Shallow slow respirations and respiratory alkalosis b. Decreased urine output and hyperkalemia c. Tachycardia and orthostatic hypotension d. Peripheral edema and dependent pulmonary crackles

ANS: C DKA leads to dehydration, which is manifested by tachycardia and orthostatic hypotension. Usually clients have Kussmaul respirations, which are fast and deep. Increased urinary output (polyuria) is severe. Because of diuresis and dehydration, peripheral edema and crackles do not occur.

1. In preparing a staff in-service presentation about diabetes mellitus, the nurse includes which information? a. Diabetes increases the risk for development of epilepsy. b. The cure for diabetes is the administration of insulin. c. Diabetes increases the risk for development of cardiovascular disease. d. Carbohydrate metabolism is altered in diabetes, but protein metabolism is normal.

ANS: C Diabetes mellitus is a major risk factor for morbidity and mortality caused by coronary artery disease, cerebrovascular disease, and peripheral vascular disease. Insulin is a lifelong treatment for some diabetic clients. Because insulin regulates the metabolism of carbohydrates, fats, and protein, abnormalities in insulin production or use alter their metabolism.

7. During assessment of a client with a 15-year history of diabetes, the nurse notes that the client has decreased tactile sensation in both feet. Which action does the nurse take first? a. Document the finding in the client's chart. b. Test sensory perception in the client's hands. c. Examine the client's feet for signs of injury. d. Notify the health care provider.

ANS: C Diabetic neuropathy is common when the disease is of long duration. The client is at great risk for injury in any area with decreased sensation because he or she is less able to feel injurious events. Feet are common locations for neuropathy and injury, so the nurse should inspect them for any signs of injury. After assessing, the nurse should document findings in the client's chart. Testing sensory perception in the hands may or may not be needed. The health care provider can be notified after assessment and documentation have been completed.

54. The nurse has been teaching a client about a new diagnosis of diabetes mellitus. Which statement by the client indicates a good understanding of self-management? a. "After bathing each day, I will inspect my feet and rub lotion between my toes and on my heels." b. "I can store 3 months' worth of insulin at room temperature as long as the bottles are not open." c. "My medical alert bracelet is important to identify me as having diabetes if I am unconscious." d. "If I travel eastward to see my family, I should plan on using more insulin on the day I travel."

ANS: C It is important to encourage clients with diabetes mellitus to wear a medical alert bracelet. This bracelet is helpful if the client becomes hypoglycemic and is unable to provide self-care. Lotion should not be applied between the toes. Insulin in active use can be stored at room temperature for 28 days; otherwise insulin is stored in the refrigerator. Eastbound travel will require a reduction in insulin.

51. The nurse is teaching a client with type 2 diabetes about acute complications. Which teaching point by the nurse is most accurate? a. Ketosis is less prevalent among obese adults owing to the protective effects of fat. b. People with type 2 diabetes have normal lipid metabolism, so ketones are not made. c. Insulin produced in type 2 diabetes prevents fat catabolism but not hyperglycemia. d. Oral antidiabetic agents do not promote the breakdown of fat for fuel (lipolysis).

ANS: C Ketosis occurs as a result of fat catabolism when intracellular glucose is unavailable for energy production. The client with type 1 diabetes becomes ketotic because he or she produces no insulin, and blood glucose cannot enter the cells. In type 2 diabetes, natural insulin production continues, although at a greatly reduced level. This level is not sufficient to keep blood glucose levels in the normal range but permits just enough glucose to enter cells for energy production, so that fats are not catabolized for this purpose. The other rationales are incorrect.

40. Three hours after surgery, the nurse notes that the breath of the client with type 1 diabetes has a "fruity" odor. Which is the nurse's best first action? a. Document the finding in the client's chart. b. Increase the IV fluid flow rate. c. Test the serum for ketone bodies. d. Perform pulmonary hygiene.

ANS: C The stress of surgery increases the action of counterregulatory hormones and suppresses the action of insulin, predisposing the client to ketoacidosis and metabolic acidosis. One manifestation of ketoacidosis is a "fruity" odor to the breath. Documentation should occur after all assessments have been completed. The other options are not needed for this problem.

5. A client with diabetes has a serum creatinine of 1.9 mg/dL. The nurse correlates which urinalysis finding with this client? a. Ketone bodies in the urine during acidosis b. Glucose in the urine during hyperglycemia c. Protein in the urine during a random urinalysis d. White blood cells in the urine during a random urinalysis

ANS: C Urine should not contain protein. The presence of proteinuria in a diabetic client marks the beginning of kidney problems known as diabetic nephropathy, which progresses eventually to end-stage kidney disease. Decline in kidney function is assessed with serum creatinine. This client's creatinine level is high. The other findings would not be correlated with declining kidney function.

42. A diabetic client has numbness and reduced sensation. Which intervention does the nurse teach this client to prevent injury? a. "Examine your feet daily using a mirror." b. "Rotate your insulin injection sites." c. "Wear white socks instead of colored socks." d. "Use a bath thermometer to test the water temperature."

ANS: D Clients with diminished sensory perception can easily experience a burn injury when bath water is too hot. Instead of checking the temperature of the water by feeling it, they should use a thermometer. Examining the feet daily does not prevent injury, although daily foot examinations are important to find problems so they can be addressed. Rotating insulin and wearing white socks also will not prevent injury.

27. A client is learning to inject insulin. Which action is important for the nurse to teach the client? a. "Do not use needles more than twice before discarding." b. "Massage the site for 1 full minute after injection." c. "Try to make the injection deep enough to enter muscle." d. "Keep the vial you are using in the pantry or the bedroom drawer."

ANS: D Cold insulin directly from the refrigerator is the most common cause of irritation (not infection) at the insulin injection site. Insulin in active use can be stored at room temperature. However, the bathroom is not the best place to store any medication because of increased heat and humidity. Needles should be used only once. Massage will not prevent or treat irritation from cold insulin. Insulin is given by subcutaneous, not intramuscular, injection.

58. A client recently diagnosed with type 1 diabetes tells the nurse, "I will never be able to stick myself with a needle." Which is the nurse's best response? a. "Try not to worry about it. We will give you your injections here in the hospital." b. "Everyone gets used to giving themselves injections. It really does not hurt." c. "I am not sure how your disease can be managed if you refuse to give yourself the shots." d. "Tell me what it is about the injections that is concerning you."

ANS: D Devote as much teaching time as possible to insulin injection and blood glucose monitoring. Clients with newly diagnosed diabetes are often fearful of giving themselves injections. If the client is worried about giving the injections, it is best to try to find out what specifically is causing the concern, so it can be addressed. Giving the injections for the client does not promote self-care ability. Telling the client that others give themselves injections may cause the client to feel badly. Stating that you don't know another way to manage the disease is dismissive of the client's concerns.

10. Which client is at greatest risk for undiagnosed diabetes mellitus? a. Young, muscular white man b. Young African-American man c. Middle-aged Asian woman d. Middle-aged American Indian woman

ANS: D Diabetes is a particular problem among African Americans, Hispanics, and American Indians. The incidence of diabetes increases in all races and ethnic groups with age. Being both an American Indian and middle-aged places a person at highest risk.

6. A young adult client newly diagnosed with type 1 diabetes mellitus has been taught about self-care. Which statement by the client indicates a good understanding of needed eye examinations? a. "At my age, I should continue seeing the ophthalmologist as I usually do." b. "I will see the eye doctor whenever I have a vision problem and yearly after age 40." c. "My vision will change quickly now. I should see the ophthalmologist twice a year." d. "Diabetes can cause blindness, so I should see the ophthalmologist yearly."

ANS: D Diabetic retinopathy is a leading cause of blindness in North America. All clients with diabetes, regardless of age, should be examined by an ophthalmologist (rather than an optometrist or optician) at diagnosis and at least yearly thereafter.

29. A client with diabetes has proliferative retinopathy, nephropathy, and peripheral neuropathy. Which statement by the client indicates a good understanding of the disease and exercise? a. "Because I have so many complications, I guess exercise is not a good idea." b. "I have so many complications that I better exercise hard to keep from getting worse." c. "I love to walk outside, but I probably better avoid doing that now." d. "I should look into swimming or water aerobics to get my exercise."

ANS: D Exercise is not contraindicated for this client, although modifications based on existing pathology are necessary to prevent further injury. Swimming or water aerobics will give the client exercise without the worry of having the correct shoes or developing a foot injury. The client can walk outside if this is the exercise that he or she prefers. The client should not exercise too vigorously.

3. The nurse is monitoring a client with hypoglycemia. Glucagon provides which function? a. It enhances the activity of insulin, restoring blood glucose levels to normal more quickly after a high-calorie meal. b. It is a storage form of glucose and can be broken down for energy when blood glucose levels are low. c. It converts excess glucose into glycogen, lowering blood glucose levels in times of excess. d. It prevents hypoglycemia by promoting release of glucose from liver storage sites.

ANS: D Glycogen is a counterregulatory hormone secreted by the alpha cells of the pancreas when blood glucose levels are low. The actions of glycogen that raise blood glucose levels include stimulating the liver to break down glycogen (glycogenolysis) and forming new glucose from protein breakdown (gluconeogenesis). The other statements are not accurate descriptions of the actions of glucagon.

23. A client has a new insulin pump. Which is the nurse's priority instruction in teaching the client? a. "Test your urine daily for ketones." b. "Use only buffered insulin." c. "Keep the insulin frozen until you need it." d. "Change the needle every 3 days."

ANS: D Having the same needle remain in place through the skin for longer than 3 days drastically increases the risk for infection in or through the delivery system. Having an insulin pump does not require the client to test for ketones in the urine. Insulin should not be frozen. Insulin is not buffered.

4. A client with untreated diabetes mellitus has polyuria, is lethargic, and has a blood glucose of 560 mg/dL. The nurse correlates the polyuria with which finding? a. Serum sodium, 163 mEq/L b. Serum creatinine, 1.6 mg/dL c. Presence of urine ketone bodies d. Serum osmolarity, 375 mOsm/kg

ANS: D Hyperglycemia causes hyperosmolarity of extracellular fluid. This leads to polyuria from an osmotic diuresis. The client's serum osmolarity is high. The client's sodium would be expected to be high owing to dehydration. Urine ketone bodies and serum creatinine are not related to the polyuria.

44. A client has long-standing diabetes mellitus. Which finding alerts the nurse to decreased kidney function in this client? a. Urine specific gravity of 1.033 b. Presence of glucose in the urine c. Presence of ketone bodies in the urine d. Sustained elevation in blood pressure

ANS: D Hypertension is both a cause of renal dysfunction and a result of renal dysfunction. Renal dysfunction often occurs in the client with diabetes. Glucose and ketones in the urine are consistent with diabetes mellitus but are not specific to renal function. Specific gravity is elevated with dehydration.

49. A client is receiving IV insulin for hyperglycemia. Which laboratory value requires immediate intervention by the nurse? a. Serum chloride level of 98 mmol/L b. Serum calcium level of 8.8 mg/dL c. Serum sodium level of 132 mmol/L d. Serum potassium level of 2.5 mmol/L

ANS: D Insulin activates the sodium-potassium ATPase pump, increasing the movement of potassium from the extracellular fluid into the intracellular fluid, resulting in hypokalemia. In hyperglycemia, hypokalemia can also result from excessive urine loss of potassium. The chloride level is normal. The calcium and sodium levels are slightly low, but this would not be related to hyperglycemia and insulin administration.

35. The nurse is teaching a client with diabetes about self-care. Which activity does the nurse teach that can decrease insulin needs? a. Reducing intake of liquids to 2 L/day b. Eating animal organ meats high in insulin c. Limiting carbohydrate intake to 100 g/day d. Walking 1 mile each day

ANS: D Moderate exercise, such as walking, helps regulate blood glucose levels on a daily basis and results in lowered insulin requirements for clients with type 1 diabetes. Restricting fluids and eating organ meats will not reduce insulin needs. People with diabetes need at least 130 grams of carbohydrates each day.

19. A client who has used insulin for diabetes control for 20 years has a spongy swelling at the site used most frequently for insulin injection. Which is the nurse's best action? a. Apply ice to this area for 20 minutes. b. Document the finding in the client's chart. c. Assess the client for other signs of cellulitis. d. Instruct the client to use a different site for injection.

ANS: D The client has lipohypertrophy as a result of repeated injections at the same site. Avoiding this site for an extended period of time allows dystrophic changes to regress or at least not to become worse. The other actions are not needed.

21. A client on an intensified insulin regimen consistently has a fasting blood glucose level between 70 and 80 mg/dL, a postprandial blood glucose level below 200 mg/dL, and a hemoglobin A1c level of 5.5%. Which is the nurse's interpretation of these findings? a. Increased risk for developing ketoacidosis b. Increased risk for developing hyperglycemia c. Signs of insulin resistance d. Good control of blood glucose

ANS: D The client is maintaining blood glucose levels within the defined ranges for goals in an intensified regimen. Because the client's glycemic control is good, he or she is not at higher risk for ketoacidosis or hyperglycemia and is not showing signs of insulin resistance.

32. A client has diabetic ketoacidosis and manifests Kussmaul respirations. What action by the nurse takes priority? a. Administration of oxygen by mask or nasal cannula b. Intravenous administration of 10% glucose c. Implementation of seizure precautions d. Administration of intravenous insulin

ANS: D The rapid, deep respiratory efforts of Kussmaul respiration is the body's attempt to reduce the acids produced by using fat rather than glucose for fuel. The client who is in ketoacidosis and who does not also have a respiratory impairment does not need additional oxygen. Only the administration of insulin will reduce this type of respiration by assisting glucose to move into cells and to be used for fuel instead of fat. Giving the client glucose would be contraindicated. The client does not require Seizure Precautions.

33. A client with type 1 diabetes asks whether an occasional glass of wine is allowed in the diet. Which is the nurse's best response? a. "Drinking any wine or alcohol will increase your insulin requirements." b. "Because of poor kidney function, people diagnosed with diabetes should avoid alcohol at all times." c. "You shouldn't drink alcohol because it will make you hungry and overeat." d. "One glass of wine is okay with a meal and is counted as two fat exchanges."

ANS: D Under normal circumstances, blood glucose levels will not be affected by moderate use of alcohol when diabetes is well controlled. Because alcohol can induce hypoglycemia, it should be ingested with or shortly after a meal. One alcoholic beverage is substituted for two fat exchanges when caloric intake is calculated. The other statements are incorrect.

50. The nurse is teaching a client about sick day management. Which statement by the nurse is most accurate? a. "Continue your prescribed exercise regimen even if you are sick." b. "Avoid eating or drinking to reduce vomiting and diarrhea." c. "Do not use insulin or take your oral antidiabetic agent if you vomit." d. "Monitor your blood glucose levels at least every 4 hours."

ANS: D When ill, the client should monitor his or her blood glucose at least every 4 hours. The other statements are inaccurate.

1. In mixing regular and NPH insulin, the nurse completes the following actions. Place these actions in the correct order. (Separate letters by a comma and space as follows: a, b, c, d.) a. Inspect bottles for expiration dates. b. Gently roll bottle of NPH in hands. c. Wash your hands. d. Inject air into the regular insulin. e. Withdraw the NPH insulin. f. Withdraw the regular insulin. g. Inject air into the NPH bottle. h. Clean rubber stoppers with an alcohol swab.

c, a, b, h, g, d, f, e After washing hands, it is important to inspect bottles and then to roll NPH to mix the insulin. It is important to inject air into the NPH bottle before placing the needle in a regular insulin bottle to avoid mixing of regular and NPH insulin. The shorter-acting insulin is always drawn up first.