Chapter 38: Agents to Control Blood Glucose Levels

The nurse is caring for a 3-year-old child newly diagnosed with type 1 diabetes. When developing the plan of care for this child, the nurse incorporates challenges the child faces that the adult does not, which includes what? (Select all that apply.) A) Children have a faster metabolic rate. B) Growth must be balanced with diet and activity. C) Insulin dose may be so small it is hard to calibrate accurately. D) Increased resistance by child to dietary restrictions is common. E) Changing metabolism makes regulating insulin difficult.

Ans: A, B, C Feedback: Treatment of diabetes in children is a difficult challenge of balancing diet, activity, growth, stressors, and insulin requirements. Children need to be carefully monitored for any sign of hypoglycemia or hyperglycemia and treated quickly because their fast metabolism and lack of body reserves can push them into a severe state quickly. Insulin dosage, especially in infants, may be so small that it is difficult to calibrate. Insulin often needs to be diluted to a volume that can be detected on the syringe. It is usually during adolescence when increased resistance to dietary restrictions and changing metabolism makes regulating insulin difficult so this would not be part of the plan of care for a 3-year-old.

The nurse is caring for a patient with renal dysfunction who requires an oral antidiabetic agent. What drug will the nurse expect to see ordered? A) Tolbutamide B) Chlorpropamide C) Tolazamide D) Chlorpromazine

Ans: A Feedback: Tolbutamide is preferred for patients with renal dysfunction, who may not be able to excrete chlorpropamide, because it is more easily cleared from the body. Tolbutamide, chlorpropamide, and tolazamide are all first-generation sulfonylureas, but tolazamide is used less frequently and is usually tried after the first two drugs have been shown to be ineffective. Chlorpromazine (Thorazine) is an antipsychotic agent.

The nurse is caring for an adolescent newly diagnosed with type 1 diabetes. The patient says, I cant believe Im going to spend the rest of my life sticking myself with needles. What future possibilities for insulin delivery can the nurse share with this patient? (Select all that apply.) A) Implantable insulin pump B) Insulin patch C) Inhaled insulin D) Oral insulin E) Pancreas transplant

Ans: A, B, C Feedback: Research is ongoing to obtain approval for an implantable insulin pump, an insulin patch, and inhaled insulin. Insulin cannot be taken orally because it is destroyed by gastric secretions and transplanting a pancreas for treatment for diabetes is not likely.

What instructions would be important to give to a 50-year-old patient with type 2 diabetes who has been switched from glyburide (DiaBeta) to repaglinide? A) It is less potent, so you will need to take a larger dose. B) It stimulates insulin production, so you need to eat soon after taking the medication. C) It is more potent and longer lasting, so you should take it every other day. D) The two medications are virtually the same.

Ans: B Feedback: Glyburide is a second-generation sulfonylurea that stimulates insulin release from the beta cells in the pancreas with a 2- to 4-hour onset of action. Repaglinide has an onset of action within 30 minutes with peak effect in 1 hour, and duration of action is approximately 3 to 4 hours. Because repaglinide has a much faster onset of action, it is important the patient eats within15 to 30 minutes after taking the drug to avoid hypoglycemia. Repaglinide is not less potent, it is not more potent, and the two medications are not virtually the same.

The diabetes nurse educator describes type 1 diabetes with what statement? A) Blood glucose level can be controlled with diet. B) Exogenous insulin is required for life. C) Oral agents can help to control blood glucose levels. D) It is always diagnosed in early childhood.

Ans: B Feedback: Type 1 diabetes results from an autoimmune disorder that destroys pancreatic beta cells. Insulin is the only effective treatment for type 1 diabetes because pancreatic beta cells are unable to secrete endogenous insulin and metabolism is severely impaired. In type 1 diabetes, blood glucose levels cannot be controlled with diet, oral agents cannot control the disease process because they stimulate insulin production, and the patient with type 1 diabetes does not produce insulin. It can be diagnosed at other stages of the life span than just in early childhood.

What is the maximum daily dosage of metformin the nurse can administer to a child aged 10 to 16 years? A) 500 mg B) 850 mg C) 2,000 mg D) 2,550 mg

Ans: C Feedback: Children should not receive more than 2,000 mg/d whereas adults should not receive more than 2,550 mg/d. The normal dosage for children is 500 mg/d and for adults is 500 to 850 mg/d.

A diabetic patient is taking regular and NPH insulin to manage his diabetes. What is the best evaluation tool to measure the overall patient response to the insulin therapy? A) Blood pressure B) Bilirubin level C) Glycosylated hemoglobin (HbAlc) levels D) Fasting blood glucose levels

Ans: C Feedback: HbAlc levels provide a 3-month average of glucose levels, which provides the best evaluation tool to measure the overall patient response to the treatment plan. Blood pressure readings would be used to evaluate a patients response to an antihypertensive drug. Bilirubin could indicate liver function. Fasting blood glucose levels provide only a baseline blood sugar and no historical overview. Comparing fasting blood glucose levels with HbAlc is like comparing a picture to a video because the HbAlc looks back across a period of 3 months whereas a blood glucose test result only tells you about the exact moment the blood was drawn.

The nurse is caring for a pregnant patient diagnosed with pregnancy-induced diabetes. What antidiabetic agent is best suited for administration to this patient? A) Metformin B) Acarbose C) Insulin D) Glyburide

Ans: C Feedback: Insulin therapy is the best choice for patients with diabetes during pregnancy and lactation, which are times of high stress and metabolic demands. Oral antidiabetic medications are contraindicated during pregnancy so metformin, acarbose, and glyburide are not the best choices.

The nurse transcribes an order for chlorpropamide (Diabinese). What is an appropriate dosage range for this medication? A) 0.25 to 3 g per day B) 2 mg per day C) 100 to 250 mg per day D) 5 mg orally daily

Ans: C Feedback: The appropriate dosage range for oral chlorpropamide is 100 to 250 mg/d. Tolbutamide is 0.25 to 3 g/d. Glimepiride is 1 to 4 mg/d. Glipizide is taken 5 mg PO daily. 35.

A patient is brought to the emergency department with severe hypoglycemia. What drug would the nurse prepare to administer intravenously? A) Diazole (Hyperstat) B) Glyburide (DiaBeta) C) Glucagon (GlucaGen) D) Insulin (Humulin R)

Ans: C Feedback: This patient will need a glucose-elevating agent. Glucagon (GlucaGen) is given parenterally only and is the preferred agent for emergency situations. Diazole is also a glucose-elevating agent but is only administered so it would take longer to take effect. Insulin would be administered for hyperglycemia. Glyburide is an oral antidiabetic agent, which is a second-generation sulfonylurea, and is administered for hyperglycemia.

A patient comes to the diabetes educator and asks about changing his insulin. The patient explains that his occupation takes him on long international flights and he does not want to administer insulin on the plane. What kind of insulin would the diabetic nurse educator seek an order for? A) Lispro (Humalog) B) Glulisine (Apidra) C) Ultralente (Humulin U Ultralente) D) Aspart (NovoLog)

Ans: C Feedback: Ultralente has a duration of 20 to 36 hours and a peak time of 10 to 30 hours. This would prevent him having to administer insulin on the airplane. Lispro has a duration of 2 to 5 hours and a peak time of 30 to 90 minutes. Glulisine has a duration of 1 to 2.5 hours and a peak time of 30 to 90 minutes. Aspart has a duration of 3 to 5 hours and a peak time of 1 to 3 hours. The last three insulin types mentioned in this Rationale would likely require administration on long plane flights.

The nurse is instructing a patient how to mix NPH insulin with regular insulin in one syringe. The nurse tells the patient the mixture must be administered within how long after it is prepared? A) 5 minutes B) 10 minutes C) 15 minutes D) 20 minutes

Ans: C Feedback: Use caution when mixing types of insulin. Administer mixtures of regular and NPH or regular and lente insulins within 15 minutes after combining them to ensure appropriate suspension and therapeutic effect.

What type of insulin would the nurse administer if the fastest therapeutic effects are needed? A) Lispro (Humalog) B) Aspart (NovoLog) C) Regular (Humulin R) D) Glulisine (Apidra)

Ans: D Feedback: Glulisine has an onset of 2 to 5 minutes and peaks in 30 to 90 minutes so it has the fastest onset of action. Lispro has an onset in <15 minutes and also peaks at 30 to 90 minutes. Aspart takes 10 to 20 minutes for onset and peeks in 1 to 3 hours. Regular insulin has a 30 to 60 minute onset and peaks in 2 to 4 hours.

With what patient would the nurse question the administration of human insulin? A) Gestational diabetes B) Type 2 diabetes controlled on oral antidiabetic agents with systemic infection C) Type 1 diabetes of many years D) Type 2 diabetes controlled by diet

Ans: D Feedback: Insulin is recommended for treatment of type 2 diabetes in patients whose diabetes cannot be controlled by diet or other pharmacotherapeutic agents. If the diabetes can be controlled by diet, the pancreas is still functioning and releasing insulin. Human insulin can be used in gestational diabetes, patients with type 2 diabetes controlled on oral antidiabetic agents with systemic infection, or patients with type 1 diabetes of many years standing.

A patient is admitted to the emergency department in diabetic ketoacidosis (DKA) with a blood glucose level of 485 mg/dL. The physician orders an initial dose of 25 U insulin IV. Which type of insulin will be administered? A) NPH insulin B) Humulin L insulin C) Humulin N insulin D) Regular insulin

Ans: D Feedback: Regular insulin is a short-acting insulin that manages the hyperglycemia and hyperkalemia resulting from DKA, which is a life-threatening complication that occurs with severe insulin deficiency. Furthermore, only regular insulin can be given IV and is the drug of choice in emergency situations. Humulin N, Humulin L, and NPH are intermediate-acting forms.

The nurse is caring for a postoperative patient whose diabetes has been well controlled on acarbose (Precose). The patient is not allowed to take anything orally following abdominal surgery and is receiving high-glucose total parenteral nutrition via a central IV line. What medication can the nurse administer IV to control the patients blood glucose level? A) Glyburide B) Acarbose C) NPH insulin D) Regular insulin

Ans: D Feedback: Only regular insulin can be administered IV. No other insulins or oral antidiabetic medications can be given IV.

The nurse is performing diabetes screening and recognizes what ethnic group is at higher risk for diabetes but is also predisposed to a higher normal range of blood glucose? A) Native Americans B) Japanese Americans C) African Americans D) Caucasian Americans

Ans: A Feedback: Certain ethnic groups tend to have a genetically predetermined variation in blood glucose levels, possibly caused by a variation in metabolism. For example, Native Americans, Hispanic Americans, and Japanese Americans have higher blood glucose levels than white Americans do. Groups that are more likely to develop diabetes mellitus include African Americans, Native Americans, and Hispanic Americans.

The nurse is caring for a patient taking Bromocriptine (Cycloset). What is an advantage of this medication? A) Reduces risk of heart attack or stroke B) Has no adverse effects C) Is taken four times a day D) Long-term studies needed

Ans: A Feedback: Bromocriptine-therapy patients had improved HbA1c levels, showing better glycemic control, and were less likely to have a heart attack or stroke or to die of heart disease. All drugs have adverse effects. Taking the medication four times a day and the need for long-term studies are not advantages of the drug.

When the nurse administers an oral combination drug called Metaglip, what doses of the two medications are being administered? A) 2.5 mg glipizide, 500 mg metformin B) 1.25 mg glyburide, 250 mg metformin C) 5 mg glipizide, 250 mg metformin D) 4 mg rosiglitazone, 500 mg metformin

Ans: A Feedback: Metaglip is a combination of 2.5 mg glipizide with 250 or 500 mg metformin or 5 mg glipizide and 500 mg metformin. Glucovance is a combination of 1.25 mg glyburide with 250 mg metformin, 2.5 mg glyburide with 500 mg metformin, and 5 mg glyburide with 500 mg of metformin. Avandamet is a combination of 1, 2, or 4 mg rosiglitazone with 500 mg metformin.

The nurse is caring for a patient with polycystic ovary syndrome. What antidiabetic drug would the nurse anticipate will be ordered? A) Metformin B) Acarbose C) Insulin D) Glyburide

Ans: A Feedback: Metformin and pioglitazone have proven effective in increasing insulin sensitivity and decreasing androgen and luteinizing hormone levels to break the cycle and allow ovulation to occur if pregnancy is desired. A fertility drug is often used with the antidiabetic agent. Other options are not appropriate because they are not indicated for treating polycystic ovary syndrome.

The nurse is preparing patient teaching for a diabetic patient who is to begin pramlintide acetate (Symlin) therapy, which will be taken in addition to insulin. What is the priority nursing instruction to include in this teaching plan? A) The drug is injected subcutaneously immediately before a major meal. B) The drug has a rapid onset of action. C) Inject the drug at least 2 inches away from any insulin injection site. D) Do not combine the drug with insulin in the same syringe.

Ans: A Feedback: Pramlintide works to modulate gastric emptying after a meal, so correct timing of administration of this drug is essential to its function. All options are appropriate instructions for this drug. However, making sure that the patient understands that injecting the medication immediately before eating a major meal is most important because it has a dramatic effect on the therapeutic action of the drug. If the medication is not given at the correct time, the other options would be insignificant.

The nurse will question what medication order for a diabetic patient who takes insulin to control his blood sugar level? A) Propranolol (Inderal) 10 mg orally t.i.d. B) Furosemide (Lasix) 60 mg/d orally C) Cefaclor (Ceclor) 250 mg orally every 8 hour D) Metoclopramide (Reglan) 20 mg PO

Ans: A Feedback: Propranolol is a beta-blocker and should be avoided in combination with insulin. The blocking of the sympathetic nervous system also blocks many of the signs and symptoms of hypoglycemia, hindering the patients ability to recognize problems. If propranolol must be taken, the nurse will need to teach this patient other ways to recognize hypoglycemia. Furosemide, cefaclor, and metoclopramide do not cause drugdrug interactions with insulin.

A patient with type 1 diabetes takes 12 units of regular insulin and 34 units of NPH insulin in the morning. How would the nurse explain why two different types of insulin are required to control the patients blood sugar? A) Different onsets and peak effects extends blood glucose control. B) The mixture makes each drug work more effectively. C) The combination reduces the adverse effects experienced. D) Patients are less likely to experience hypoglycemia.

Ans: A Feedback: Regular insulin will begin working within 30 to 60 minutes and peak within 2 to 4 hours and a 6- to 12-hour duration of action whereas NPH insulin has an onset of 60 to 90 minutes and peaks in 4 to 12 hours, with a 24-hour duration of action. By giving both drugs at once, the patient gets rapid blood glucose control within 30 minutes from the regular insulin and the control lasts 24 hours due to NPHs long duration of action. The combination does not make the drugs work more effectively, it does not reduce adverse effects, and patients are more likely to experience hypoglycemia if they do not eat properly.

The nurse is caring for an obese woman who was just diagnosed with type 2 diabetes. When developing this patients plan of care, what is the priority nursing diagnosis? A) Imbalanced nutrition: more than body requirements related to obesity B) Risk for unstable blood glucose related to ineffective dosing of antidiabetic agents C) Disturbed sensory perception related to glucose levels D) Ineffective coping related to diagnosis and therapy

Ans: A Feedback: The priority with this patient is to address her obesity because losing weight may eliminate the problem. Depending on the agent that is ordered, there may be risk for unstable blood glucose and the patient may need support to cope with the diagnosis but these are not the priority concern. Disturbed sensory perception is not indicated to be a problem at this time.

The nurse is teaching the patient about the newly prescribed external insulin pump. What are priority teaching points for the nurse to include? (Select all that apply.) A) Watch for signs and symptoms of infection. B) Check blood glucose frequently. C) Change tubing frequently. D) Have pump calibrated weekly. E) Added insulin requires separate injection site.

Ans: A, B, C, D Feedback: This pump device can be worn on a belt or hidden in a pocket and is attached to a small tube inserted into the subcutaneous tissue of the abdomen. The device slowly leaks a base rate of insulin into the abdomen all day; the patient can pump or inject booster doses throughout the day to correspond with meals and activity. The device does have several disadvantages. For example, it is awkward, the tubing poses an increased risk of infection and requires frequent changing, and the patient has to frequently check blood glucose levels throughout the day to monitor response. There is no need to calibrate the pump.

The nurse admits a patient to the emergency department and recognizes the patient is in diabetic ketoacidosis (DKA) when what manifestations are assessed? (Select all that apply.) A) Fruity breath B) Edema C) Dehydration D) Agitation E) slow and deep respirations

Ans: A, C, E Feedback: Signs of impending dangerous complications of hyperglycemia such as DKA include the following: fruity breath as the ketones build up in the system and are excreted through the lungs; dehydration as fluid and important electrolytes are lost through the kidneys; slow and deep respirations (Kussmauls respirations) as the body tries to rid itself of high acid levels; loss of orientation and coma rather than agitation are to be expected. Edema is not a sign of DKA.

The nurse suspects the diabetic patient may be having a hypoglycemic reaction when what manifestation is assessed? A) Dry, flaky skin B) Diaphoresis C) Flushing of the face D) Fruity breath

Ans: B Feedback: Diaphoresis and cool clammy skin are signs of hypoglycemia. A fruity breath is seen with ketoacidosis. Flushing of the face is associated with hyperglycemia.

The patient with diabetes asks the nurse why different oral antidiabetic agents are ordered instead of just one drug. What is the nurses best explanation of the benefit of combining different agents? A) Maximum effects B) Additive effects C) Minimalistic effects D) Synergistic effects

Ans: B Feedback: Five types of oral antidiabetic agents exist, all of which may be used to treat type 2 diabetes when diet and exercise alone fail to control the disorder. The drugs lower blood sugar by different mechanisms and may be used in various combinations for additive effects.

The home care nurse is caring for an older adult patient with visual impairment who cannot see the numbers on the syringe when preparing insulin for administration and cannot afford the increased cost of prefilled auto syringes. What strategy might the nurse use to help this patient comply with insulin needs between visits? A) Change the patient to oral antidiabetics. B) Prepare a weeks supply of syringes and refrigerate. C) Have the patient use a magnifying glass. D) Ask a neighbor to come over every day to prepare the medication.

Ans: B Feedback: Older adults can have many underlying problems that complicate diabetic therapy. Poor vision and/or coordination may make it difficult to prepare a syringe. A weeks supply of syringes can be prepared and refrigerated for the usual dose of insulin. If the patient is using insulin it is most likely because oral antidiabetic medications dont work. A magnifying glass is impractical because drawing up medication requires two hands and a magnifying glass will not help the patient to see well enough to be safe. It is a big imposition to expect a neighbor to be constantly available and this would not be the best choice.

A patient with type 2 diabetes presents at the clinic for a routine follow-up appointment. The patient asks the nurse whether she can take the herbal supplement ginseng. What is the correct response by the nurse? A) It increases the risk for high blood glucose levels. B) It increases the risk for low blood glucose levels. C) There is no research to indicate what effect it will have. D) There is no reason ginseng cannot be taken by people with diabetes.

Ans: B Feedback: Patients being treated with antidiabetic therapies are at an increased risk of developing hypoglycemia if they use herbals containing juniper berries, ginseng, garlic, fenugreek, coriander, dandelion root, or celery. If a patient uses these therapies, blood glucose levels should be monitored closely and appropriate dose adjustment made in the prescribed drug.

An type 1 (insulin-dependent) diabetic reports recurrent hypoglycemia late in the morning. After collecting his health history what finding would the nurse suspect is causing the late morning hypoglycemia? A) The patient likes to nap after work before his evening meal. B) The patient jogs 2 miles in the morning before he goes to work. C) The patient likes to have an early lunch with his girlfriend. D) The patient eats oatmeal early in the morning for breakfast.

Ans: B Feedback: Physical exercise, such as jogging, changes insulin requirements and may result in a delayed hypoglycemic reaction. The fact that he likes to nap before dinner and has an early lunch is unrelated to his hypoglycemia. The patient eating oatmeal early in the morning would help stabilize his blood sugars until later in the morning, but the jogging would have a dramatic effect.

The patient, newly diagnosed with diabetic retinopathy, asks what caused this disorder. What is the nurses best response? A) Inability of cells in the eye to reproduce B) Increase of aqueous humor in the eye C) Decrease of nerve innervations throughout the eye D) Oxygen cannot diffuse rapidly across the membrane to tissues in the eye

Ans: D Feedback: The bodys inability to effectively cope with carbohydrate, fat, and protein metabolism over a long period of time results in a thickening of the basement membrane in large and small blood vessels. This thickening leads to changes in oxygenation of the lining of the vessels causing damage and narrowing of the vessels. The decreased blood flow through the vessels results in the inability of oxygen to rapidly diffuse across the membrane to the tissues of the eye. The tiny vessels of the eye are narrowed and closed, which causes loss of vision. Increase of aqueous humor is seen in glaucoma. Inability of cell replication and decrease in nerve innervations throughout the eye is not associated with retinopathy.

What outcome would best indicate the nurses teaching was effective and that drug therapy was appropriate? A) The patient can explain how to take the medication. B) The patient demonstrates the correct procedure for monitoring blood sugar. C) The patient follows an appropriate diet. D) Blood glucose level is stable with no diabetic complications.

Ans: D Feedback: The single best indicator, and the goal of treatment, is to help the patient maintain a stable blood glucose level so as to be able to avoid any complications. For the patient to maintain a stable blood glucose level, he needs to understand how to take his medication, to check his blood sugar level, and to follow an appropriate diet, but the best indicator is the stable glucose level.

The nurse, working in the emergency department, receives a patient following a motor vehicle accident whose medical history is unknown with a blood glucose level of 325 mg/dL. What rationale does the nurse provide explaining this elevated blood glucose level? A) The patients accident was caused by diabetic ketoacidosis (DKA). B) The patient has not been taking the antidiabetic agent as prescribed. C) The patient most likely just finished a meal. D) The stress reaction caused an increase in blood sugar.

Ans: D Feedback: The stress reaction elevates the blood glucose concentration above the normal range. In severe stress situations, the blood glucose level can be very high (300 to 400 mg/dL). The body uses that energy to fight the insult or flee from the stressor. The patient may or may not be diabetic so this is not DKA, not an indication of medication noncompliance, and not an indication the patient had just eaten.

What antidiabetic agent is approved for the nurse to administer to children 10 years old and older with type 2 diabetes? A) Pioglitazone B) Repaglinide C) Liraglutide D) Metformin

Ans: D Feedback: Metformin is the only oral antidiabetic drug approved for children. It has established dosage for children 10 years of age and older. With the increasing number of children being diagnosed with type 2 diabetes, the use of other agents in children is being tested. Because metformin is the only drug approved for use with children, pioglitazone, repaglinide, and liraglutide would not be appropriate.