Diabetes

1303 KEY: Diabetes mellitus| health screening MSC: Integrated Process: Teaching/Learning NOT:Client Needs Category: Health Promotion 4.A nurse assesses a client who has a 15-year history of diabetes and notes decreased tactile sensation in both feet. Which action should the nurse take first? a. Document the finding in the clients chart. b. Assess tactile sensation in the clients hands. c. Examine the clients feet for signs of injury. d. Notify the health care provider.

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 assessment, the nurse should document findings in the clients 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. DIF:Applying/Application

1160 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 31. A 26-year-old patient with diabetes rides a bicycle to and from work every day. Which site should the nurse teach the patient to administer the morning insulin? a. thigh. b. buttock. c. abdomen. d. upper arm.

C Patients should be taught not to administer insulin into a site that will be exercised because exercise will increase the rate of absorption. The thigh, buttock, and arm are all exercised by riding a bicycle. DIF: Cognitive Level: Apply (application)

1167 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 4. The nurse is assessing a 22-year-old patient experiencing the onset of symptoms of type 1 diabetes. Which question is most appropriate for the nurse to ask? a. Are you anorexic? b. Is your urine dark colored? c. Have you lost weight lately? d. Do you crave sugary drinks?

C Weight loss occurs because the body is no longer able to absorb glucose and starts to break down protein and fat for energy. The patient is thirsty but does not necessarily crave sugar-containing fluids. Increased appetite is a classic symptom of type 1 diabetes. With the classic symptom of polyuria, urine will be very dilute. DIF: Cognitive Level: Apply (application)

1162 TOP: Nursing Process: Evaluation MSC: NCLEX: Health Promotion and Maintenance 14. A 32-year-old patient with diabetes is starting on intensive insulin therapy. Which type of insulin will the nurse discuss using for mealtime coverage? a. Lispro (Humalog) b. Glargine (Lantus) c. Detemir (Levemir) d. NPH (Humulin N)

A Rapid- or short-acting insulin is used for mealtime coverage for patients receiving intensive insulin therapy. NPH, glargine, or detemir will be used as the basal insulin. DIF: Cognitive Level: Apply (application)

N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Nursing Process (Evaluation) 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 clients clinical manifestations have not changed 5 minutes later. Which is the nurses 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.

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. DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Nursing Process (Evaluation) 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.

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. DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesAdverse Reactions/Contraindications/Side Effects/Interactions) MSC: Integrated Process: Nursing Process (Analysis) 17. A client with diabetes asks why more than one injection of insulin is required each day. Which is the nurses 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.

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. DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Nursing Process (Implementation) 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.

B Glucagon administration often induces vomiting, increasing the clients risk for aspiration. The other actions are not required. DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesAdverse Effects/Contraindications/Side Effects/Interactions) MSC: Integrated Process: Nursing Process (Implementation) 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.

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. DIF: Cognitive Level: Comprehension/Understanding

1179 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 25. Which question during the assessment of a diabetic patient will help the nurse identify autonomic neuropathy? a. Do you feel bloated after eating? b. Have you seen any skin changes? c. Do you need to increase your insulin dosage when you are stressed? d. Have you noticed any painful new ulcerations or sores on your feet?

A Autonomic neuropathy can cause delayed gastric emptying, which results in a bloated feeling for the patient. The other questions are also appropriate to ask but would not help in identifying autonomic neuropathy. DIF: Cognitive Level: Apply (application)

1165-1166 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 9. In order to assist an older diabetic patient to engage in moderate daily exercise, which action is most important for the nurse to take? a. Determine what type of activities the patient enjoys. b. Remind the patient that exercise will improve self-esteem. c. Teach the patient about the effects of exercise on glucose level. d. Give the patient a list of activities that are moderate in intensity.

A Because consistency with exercise is important, assessment for the types of exercise that the patient finds enjoyable is the most important action by the nurse in ensuring adherence to an exercise program. The other actions will also be implemented but are not the most important in improving compliance. DIF: Cognitive Level: Apply (application)

1327 KEY: Diabetes mellitus| foot care MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 4.A nurse provides diabetic education at a public health fair. Which disorders should the nurse include as complications of diabetes mellitus? (Select all that apply.) a. Stroke b. Kidney failure c. Blindness d. Respiratory failure e. Cirrhosis

A, B, C Complications of diabetes mellitus are caused by macrovascular and microvascular changes. Macrovascular complications include coronary artery disease, cerebrovascular disease, and peripheral vascular disease. Microvascular complications include nephropathy, retinopathy, and neuropathy. Respiratory failure and cirrhosis are not complications of diabetes mellitus. DIF:Understanding/Comprehension

1303 KEY: Diabetes mellitus| health screening MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation 5.A nurse collaborates with the interdisciplinary team to develop a plan of care for a client who is newly diagnosed with diabetes mellitus. Which team members should the nurse include in this interdisciplinary team meeting? (Select all that apply.) a. Registered dietitian b. Clinical pharmacist c. Occupational therapist d. Health care provider e. Speech-language pathologist

A, B, D When planning care for a client newly diagnosed with diabetes mellitus, the nurse should collaborate with a registered dietitian, clinical pharmacist, and health care provider. The focus of treatment for a newly diagnosed client would be nutrition, medication therapy, and education. The nurse could also consult with a diabetic educator. There is no need for occupational therapy or speech therapy at this time. DIF:Applying/Application

1333 KEYiabetes mellitus| hyperglycemia MSC:Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation 3.A nurse teaches a client with diabetes mellitus about foot care. Which statements should the nurse include in this clients teaching? (Select all that apply.) a. Do not walk around barefoot. b. Soak your feet in a tub each evening. c. Trim toenails straight across with a nail clipper. d. Treat any blisters or sores with Epsom salts. e. Wash your feet every other day.

A, C Clients who have diabetes mellitus are at high risk for wounds on the feet secondary to peripheral neuropathy and poor arterial circulation. The client should be instructed to not walk around barefoot or wear sandals with open toes. These actions place the client at higher risk for skin breakdown of the feet. The client should be instructed to trim toenails straight across with a nail clipper. Feet should be washed daily with lukewarm water and soap, but feet should not be soaked in the tub. The client should contact the provider immediately if blisters or sores appear and should not use home remedies to treat these wounds. DIF:Understanding/Comprehension

1307 KEYiabetes mellitus| health screening MSC:Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 2.A nurse assesses a client who is experiencing diabetic ketoacidosis (DKA). For which manifestations should the nurse monitor the client? (Select all that apply.) a. Deep and fast respirations b. Decreased urine output c. Tachycardia d. Dependent pulmonary crackles e. Orthostatic hypotension

A, C, E 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. DIF:Applying/Application

1161 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity OTHER 1. In which order will the nurse take these steps to prepare NPH 20 units and regular insulin 2 units using the same syringe? (Put a comma and a space between each answer choice [A, B, C, D, E]). a. Rotate NPH vial. b. Withdraw regular insulin. c. Withdraw 20 units of NPH. d. Inject 20 units of air into NPH vial. e. Inject 2 units of air into regular insulin vial.

A, D, E, B, C When mixing regular insulin with NPH, it is important to avoid contact between the regular insulin and the additives in the NPH that slow the onset, peak, and duration of activity in the longer-acting insulin. DIF: Cognitive Level: Understand (comprehension)

N/A TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationMedical Emergencies) MSC: Integrated Process: Nursing Process (Analysis) MULTIPLE RESPONSE 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

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. DIF: Cognitive Level: Application/Applying or higher

1334 KEYiabetes mellitus| hypoglycemia MSC:Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care MULTIPLE RESPONSE 1.A nurse assesses clients at a health fair. Which clients should the nurse counsel to be tested for diabetes? (Select all that apply.) a. 56-year-old African-American male b. Female with a 30-pound weight gain during pregnancy c. Male with a history of pancreatic trauma d. 48-year-old woman with a sedentary lifestyle e. Male with a body mass index greater than 25 kg/m2 f. 28-year-old female who gave birth to a baby weighing 9.2 pounds

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. DIF:Applying/Application

1314 KEYiabetes mellitus| insulin| medication safety MSC:Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 43.A nurse prepares to administer prescribed regular and NPH insulin. Place the nurses actions in the correct order to administer these medications. 1. Inspect bottles for expiration dates. 2. Gently roll the bottle of NPH between the hands. 3. Wash your hands. 4. Inject air into the regular insulin. 5. Withdraw the NPH insulin. 6. Withdraw the regular insulin. 7. Inject air into the NPH bottle. 8. Clean rubber stoppers with an alcohol swab. a. 1, 3, 8, 2, 4, 6, 7, 5 b. 3, 1, 2, 8, 7, 4, 6, 5 c. 8, 1, 3, 2, 4, 6, 7, 5 d. 2, 3, 1, 8, 7, 5, 4, 6

B After washing hands, it is important to inspect the bottles and then to roll the NPH to mix the insulin. Rubber stoppers should be cleaned with alcohol after rolling the NPH and before sticking a needle into either bottle. 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. DIF:Applying/Application

1185 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment 40. An active 28-year-old male with type 1 diabetes is being seen in the endocrine clinic. Which finding may indicate the need for a change in therapy? a. Hemoglobin A1C level 6.2% b. Blood pressure 146/88 mmHg c. Heart rate at rest 58 beats/minute d. High density lipoprotein (HDL) level 65 mg/dL

B To decrease the incidence of macrovascular and microvascular problems in patients with diabetes, the goal blood pressure is usually 130/80. An A1C less than 6.5%, a low resting heart rate (consistent with regular aerobic exercise in a young adult), and an HDL level of 65 mg/dL all indicate that the patients diabetes and risk factors for vascular disease are well controlled. DIF: Cognitive Level: Apply (application)

1179 OBJ: Special Questions: Prioritization; Multiple Patients TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment MULTIPLE RESPONSE 1. To monitor for complications in a patient with type 2 diabetes, which tests will the nurse in the diabetic clinic schedule at least annually (select all that apply)? a. Chest x-ray b. Blood pressure c. Serum creatinine d. Urine for microalbuminuria e. Complete blood count (CBC) f. Monofilament testing of the foot

B, C, D, F Blood pressure, serum creatinine, urine testing for microalbuminuria, and monofilament testing of the foot are recommended at least annually to screen for possible microvascular and macrovascular complications of diabetes. Chest x-ray and CBC might be ordered if the diabetic patient presents with symptoms of respiratory or infectious problems but are not routinely included in screening. DIF: Cognitive Level: Apply (application)

N/A TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology) MSC: Integrated Process: Teaching/Learning 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.

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. DIF: Cognitive Level: Application/Applying or higher

1335 KEY: Diabetes mellitus| hyperglycemia MSC: Integrated Process: Teaching/Learning NOT:Client Needs Category: Health Promotion and Maintenance 34.A nurse assesses a client who 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. b. Blood osmolarity has decreased. c. Glasgow Coma Scale score is unchanged. d. Urine remains negative for ketone bodies.

C A slow but steady improvement in central nervous system functioning is the best indicator of therapy effectiveness for HHS. Lack of improvement in the level of consciousness may indicate inadequate rates of fluid replacement. The Glasgow Coma Scale assesses the clients state of consciousness against criteria of a scale including best eye, verbal, and motor responses. An increase in serum potassium, decreased blood osmolality, and urine negative for ketone bodies do not indicate adequacy of treatment. DIF:Applying/Application

1166-1167 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 2. A 48-year-old male patient screened for diabetes at a clinic has a fasting plasma glucose level of 120 mg/dL (6.7 mmol/L). The nurse will plan to teach the patient about a. self-monitoring of blood glucose. b. using low doses of regular insulin. c. lifestyle changes to lower blood glucose. d. effects of oral hypoglycemic medications.

C The patients impaired fasting glucose indicates prediabetes, and the patient should be counseled about lifestyle changes to prevent the development of type 2 diabetes. The patient with prediabetes does not require insulin or oral hypoglycemics for glucose control and does not need to self-monitor blood glucose. DIF: Cognitive Level: Apply (application)

p. 1444 TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Analysis) 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 nurses best first action? a. Document the finding in the clients chart. b. Increase the IV fluid flow rate. c. Test the serum for ketone bodies. d. Perform pulmonary hygiene.

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. DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Analysis) 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.

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. DIF: Cognitive Level: Comprehension/Understanding

1156 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 3. A 28-year-old male patient with type 1 diabetes reports how he manages his exercise and glucose control. Which behavior indicates that the nurse should implement additional teaching? a. The patient always carries hard candies when engaging in exercise. b. The patient goes for a vigorous walk when his glucose is 200 mg/dL. c. The patient has a peanut butter sandwich before going for a bicycle ride. d. The patient increases daily exercise when ketones are present in the urine.

D When the patient is ketotic, exercise may result in an increase in blood glucose level. Type 1 diabetic patients should be taught to avoid exercise when ketosis is present. The other statements are correct. DIF: Cognitive Level: Apply (application)

N/A TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology) MSC: Integrated Process: Nursing Process (Assessment) OTHER 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. DIF: Cognitive Level: Application/Applying or higher

1179 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 45. Which nursing action can the nurse delegate to unlicensed assistive personnel (UAP) who are working in the diabetic clinic? a. Measure the ankle-brachial index. b. Check for changes in skin pigmentation. c. Assess for unilateral or bilateral foot drop. d. Ask the patient about symptoms of depression.

A Checking systolic pressure at the ankle and brachial areas and calculating the ankle-brachial index is a procedure that can be done by UAP who have been trained in the procedure. The other assessments require more education and critical thinking and should be done by the registered nurse (RN). DIF: Cognitive Level: Apply (application)

1330 KEYiabetes mellitus| hyperglycemia| postoperative nursing MSC:Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 26.A preoperative nurse assesses a client who has type 1 diabetes mellitus prior to a surgical procedure. The clients blood glucose level is 160 mg/dL. Which action should the nurse take? a. Document the finding in the clients chart. b. Administer a bolus of regular insulin IV. c. Call the surgeon to cancel the procedure. d. Draw blood gases to assess the metabolic state.

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, canceling the procedure, or drawing arterial blood gases is not required. DIF:Applying/Application

N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Implementation) 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 nurses best action? a. Document the finding in the clients 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.

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. DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesMedication Administration) MSC: Integrated Process: Nursing Process (Implementation) 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

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. DIF: Cognitive Level: Comprehension/Understanding

p. 1416 TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology) MSC: Integrated Process: Teaching/Learning 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.

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. DIF: Cognitive Level: Application/Applying or higher

1307 KEY: Diabetes mellitus| genetics MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 6.A nurse teaches a client who is diagnosed with diabetes mellitus. Which statement should the nurse include in this clients plan of care to delay the onset of microvascular and macrovascular complications? a. Maintain tight glycemic control and prevent hyperglycemia. b. Restrict your fluid intake to no more than 2 liters a day. c. Prevent hypoglycemia by eating a bedtime snack. d. Limit your intake of protein to prevent ketoacidosis.

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. Restricting fluid intake is not part of the treatment plan for clients with diabetes. Preventing hypoglycemia and ketosis, although important, are not as important as maintaining daily glycemic control. DIF:Applying/Application

1157 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 34. A 27-year-old patient admitted with diabetic ketoacidosis (DKA) has a serum glucose level of 732 mg/dL and serum potassium level of 3.1 mEq/L. Which action prescribed by the health care provider should the nurse takefirst? a. Place the patient on a cardiac monitor. b. Administer IV potassium supplements. c. Obtain urine glucose and ketone levels. d. Start an insulin infusion at 0.1 units/kg/hr.

A Hypokalemia can lead to potentially fatal dysrhythmias such as ventricular tachycardia and ventricular fibrillation, which would be detected with electrocardiogram (ECG) monitoring. Because potassium must be infused over at least 1 hour, the nurse should initiate cardiac monitoring before infusion of potassium. Insulin should not be administered without cardiac monitoring because insulin infusion will further decrease potassium levels. Urine glucose and ketone levels are not urgently needed to manage the patients care. DIF: Cognitive Level: Apply (application)

N/A TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication) MSC: Integrated Process: Caring 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.

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. DIF: Cognitive Level: Application/Applying or higher

1324 KEYiabetes mellitus| pancreas-kidney transplant MSC:Integrated Process: Caring NOT: Client Needs Category: Psychosocial Integrity 24.After teaching a client who is recovering from pancreas transplantation, the nurse assesses the clients understanding. Which statement made by the client indicates a need for additional education? a. If I develop an infection, I should stop taking my corticosteroid. b. If I have pain over the transplant site, 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.

A Immunosuppressive agents should not be stopped without the consultation of the transplantation physician, even if an infection is present. Stopping immunosuppressive therapy endangers the transplanted organ. The other statements are correct. Pain over the graft site may indicate rejection. Anti-rejection drugs cause immunosuppression, 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. DIF:Applying/Application

1159 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 13. Which patient action indicates a good understanding of the nurses teaching about the use of an insulin pump? a. The patient programs the pump for an insulin bolus after eating. b. The patient changes the location of the insertion site every week. c. The patient takes the pump off at bedtime and starts it again each morning. d. The patient plans for a diet that is less flexible when using the insulin pump.

A In addition to the basal rate of insulin infusion, the patient will adjust the pump to administer a bolus after each meal, with the dosage depending on the oral intake. The insertion site should be changed every 2 or 3 days. There is more flexibility in diet and exercise when an insulin pump is used. The pump will deliver a basal insulin rate 24 hours a day. DIF: Cognitive Level: Apply (application)

1314 KEYiabetes mellitus| laboratory values MSC:Integrated Process: Nursing Process: Evaluation NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 42.A nurse prepares to administer insulin to a client at 1800. The clients medication administration record contains the following information: Insulin glargine: 12 units daily at 1800 Regular insulin: 6 units QID at 0600, 1200, 1800, 2400 Based on the clients medication administration record, which action should the nurse take? a. Draw up and inject the insulin glargine first, and then draw up and inject the regular insulin. b. Draw up and inject the insulin glargine first, wait 20 minutes, and 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.

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 and then the regular insulin right afterward. DIF:Applying/Application

N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesAdverse Effects/Contraindications/Side Effects/Interactions) MSC: Integrated Process: Nursing Process (Implementation) 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.

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. DIF: Cognitive Level: Application/Applying or higher

1321 KEYiabetes mellitus| hypoglycemia MSC:Integrated Process: Nursing Process: Evaluation NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 15.A nurse cares for a client with diabetes mellitus who is visually impaired. The client asks, Can I ask my niece to prefill my syringes and then store them for later use when I need them? How should the nurse respond? a. Yes. Prefilled syringes can be stored for 3 weeks in the refrigerator in a vertical position with the needle pointing up. b. Yes. Syringes can be filled with insulin and stored for a month in a location that is protected from light. c. Insulin reacts with plastic, so prefilled syringes are okay, but you will need to use glass syringes. d. No. Insulin syringes cannot be prefilled and stored for any length of time outside of the container.

A Insulin is relatively stable when stored in a cool, dry place away from light. When refrigerated, prefilled plastic syringes are stable for up to 3 weeks. They should be stored in the refrigerator in the vertical position with the needle pointing up to prevent suspended insulin particles from clogging the needle. DIF:Remembering/Knowledge

N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesExpected Actions/Outcomes) MSC: Integrated Process: Nursing Process (Evaluation) 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 nurses 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.

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. DIF: Cognitive Level: Comprehension/Understanding

N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Nursing Process (Evaluation) 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

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. DIF: Cognitive Level: Application/Applying or higher

1318 KEY: Diabetes mellitus| exercise MSC: Integrated Process: Teaching/Learning NOT:Client Needs Category: Health Promotion and Maintenance 18.An emergency department nurse assesses a client with ketoacidosis. Which clinical manifestation should 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

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. Tremors, elevated temperature, and orthostatic hypotension are not associated with ketoacidosis. DIF:Applying/Application

1179 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 37. A female patient is scheduled for an oral glucose tolerance test. Which information from the patients health history is most important for the nurse to communicate to the health care provider? a. The patient uses oral contraceptives. b. The patient runs several days a week. c. The patient has been pregnant three times. d. The patient has a family history of diabetes.

A Oral contraceptive use may falsely elevate oral glucose tolerance test (OGTT) values. Exercise and a family history of diabetes both can affect blood glucose but will not lead to misleading information from the OGTT. History of previous pregnancies may provide informational about gestational glucose tolerance, but will not lead to misleading information from the OGTT. DIF: Cognitive Level: Apply (application)

N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Analysis) 8. A clients father has type 1 diabetes mellitus. The client asks if she is in danger of developing the disease as well. Which is the nurses 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.

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. DIF: Cognitive Level: Comprehension/Understanding

1321 KEYiabetes mellitus| neuropathy MSC:Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 5.A nurse cares for a client who has a family history of diabetes mellitus. The client states, My father has type 1 diabetes mellitus. Will I develop this disease as well? How should the nurse respond? a. Your risk of diabetes is higher than the general population, but it may not occur. b. No genetic risk is associated with the development of type 1 diabetes mellitus. c. The risk for becoming a diabetic is 50% because of how it is inherited. d. Female children do not inherit diabetes mellitus, but male children will.

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. DIF:Understanding/Comprehension

1186 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 10. Which statement by the patient indicates a need for additional instruction in administering insulin? a. I need to rotate injection sites among my arms, legs, and abdomen each day. b. I can buy the 0.5 mL syringes because the line markings will be easier to see. c. I should draw up the regular insulin first after injecting air into the NPH bottle. d. I do not need to aspirate the plunger to check for blood before injecting insulin.

A Rotating sites is no longer recommended because there is more consistent insulin absorption when the same site is used consistently. The other patient statements are accurate and indicate that no additional instruction is needed. DIF: Cognitive Level: Apply (application)

N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesExpected Actions/Outcomes) MSC: Integrated Process: Teaching/Learning 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.

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. DIF: Cognitive Level: Application/Applying or higher

1314 KEYiabetes mellitus| insulin| medication safety MSC:Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 13.After teaching a client with diabetes mellitus to inject insulin, the nurse assesses the clients understanding. Which statement made by the client indicates a need for additional teaching? a. The lower abdomen is the best location because it is closest to the pancreas. b. I can reach my thigh the best, so I will use the different areas of my thighs. 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.

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. DIF:Applying/Application

1157 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 7. A 38-year-old patient who has type 1 diabetes plans to swim laps daily at 1:00 PM. The clinic nurse will plan to teach the patient to a. check glucose level before, during, and after swimming. b. delay eating the noon meal until after the swimming class. c. increase the morning dose of neutral protamine Hagedorn (NPH) insulin. d. time the morning insulin injection so that the peak occurs while swimming.

A The change in exercise will affect blood glucose, and the patient will need to monitor glucose carefully to determine the need for changes in diet and insulin administration. Because exercise tends to decrease blood glucose, patients are advised to eat before exercising. Increasing the morning NPH or timing the insulin to peak during exercise may lead to hypoglycemia, especially with the increased exercise. DIF: Cognitive Level: Apply (application)

1314 KEYiabetes mellitus| insulin| medication safety MSC:Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 14.A nurse assesses a client with diabetes mellitus and notes the client only responds to a sternal rub by moaning, has capillary blood glucose of 33 g/dL, and has an intravenous line that is infiltrated with 0.45% normal saline. Which action should the nurse take first? a. Administer 1 mg of intramuscular glucagon. b. Encourage the client to drink orange juice. c. Insert a new intravenous access line. d. Administer 25 mL dextrose 50% (D50) IV push.

A The clients blood glucose level is dangerously low. The nurse needs to administer glucagon IM immediately to increase the clients blood glucose level. The nurse should insert a new IV after administering the glucagon and can use the new IV site for future doses of D50 if the clients blood glucose level does not rise. Once the client is awake, orange juice may be administered orally along with a form of protein such as a peanut butter. DIF:Applying/Application

1157 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 6. A 55-year-old female patient with type 2 diabetes has a nursing diagnosis of imbalanced nutrition: more than body requirements. Which goal is most important for this patient? a. The patient will reach a glycosylated hemoglobin level of less than 7%. b. The patient will follow a diet and exercise plan that results in weight loss. c. The patient will choose a diet that distributes calories throughout the day. d. The patient will state the reasons for eliminating simple sugars in the diet.

A The complications of diabetes are related to elevated blood glucose, and the most important patient outcome is the reduction of glucose to near-normal levels. The other outcomes also are appropriate but are not as high in priority. DIF: Cognitive Level: Apply (application)

1176 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 35. A 54-year-old patient is admitted with diabetic ketoacidosis. Which admission order should the nurse implement first? a. Infuse 1 liter of normal saline per hour. b. Give sodium bicarbonate 50 mEq IV push. c. Administer regular insulin 10 U by IV push. d. Start a regular insulin infusion at 0.1 units/kg/hr.

A The most urgent patient problem is the hypovolemia associated with diabetic ketoacidosis (DKA), and the priority is to infuse IV fluids. The other actions can be done after the infusion of normal saline is initiated. DIF: Cognitive Level: Apply (application)

1183 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 26. Which information will the nurse include in teaching a female patient who has peripheral arterial disease, type 2 diabetes, and sensory neuropathy of the feet and legs? a. Choose flat-soled leather shoes. b. Set heating pads on a low temperature. c. Use callus remover for corns or calluses. d. Soak feet in warm water for an hour each day.

A The patient is taught to avoid high heels and that leather shoes are preferred. The feet should be washed, but not soaked, in warm water daily. Heating pad use should be avoided. Commercial callus and corn removers should be avoided. The patient should see a specialist to treat these problems. DIF: Cognitive Level: Apply (application)

1161 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 12. A patient receives aspart (NovoLog) insulin at 8:00 AM. Which time will it be most important for the nurse to monitor for symptoms of hypoglycemia? a. 10:00 AM b. 12:00 AM c. 2:00 PM d. 4:00 PM

A The rapid-acting insulins peak in 1 to 3 hours. The patient is not at a high risk for hypoglycemia at the other listed times, although hypoglycemia may occur. DIF: Cognitive Level: Understand (comprehension)

1186 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 44. The nurse has administered 4 oz of orange juice to an alert patient whose blood glucose was 62 mg/dL. Fifteen minutes later, the blood glucose is 67 mg/dL. Which action should the nurse take next? a. Give the patient 4 to 6 oz more orange juice. b. Administer the PRN glucagon (Glucagon) 1 mg IM. c. Have the patient eat some peanut butter with crackers. d. Notify the health care provider about the hypoglycemia.

A The rule of 15 indicates that administration of quickly acting carbohydrates should be done 2 to 3 times for a conscious patient whose glucose remains less than 70 mg/dL before notifying the health care provider. More complex carbohydrates and fats may be used once the glucose has stabilized. Glucagon should be used if the patients level of consciousness decreases so that oral carbohydrates can no longer be given. DIF: Cognitive Level: Apply (application)

N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesExpected Actions/Outcomes) MSC: Integrated Process: Nursing Process (Evaluation) 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 nurses first action? a. Review results of liver enzyme studies. b. Document the report in the clients chart. c. Instruct the client to increase water intake. d. Test a sample of urine for occult blood.

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 clients 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. DIF: Cognitive Level: Application/Applying or higher

1329 KEYiabetes mellitus| nutritional requirements MSC:Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort 31.A nurse assesses a client who has diabetes mellitus and notes the client is awake and alert, but shaky, diaphoretic, and weak. Five minutes after administering a half-cup of orange juice, the clients clinical manifestations have not changed. Which action should the nurse take next? a. Administer another half-cup of orange juice. b. Administer a half-ampule of dextrose 50% intravenously. c. Administer 10 units of regular insulin subcutaneously. d. Administer 1 mg of glucagon intramuscularly.

A This client is experiencing mild hypoglycemia. For mild hypoglycemic manifestations, the nurse should administer oral glucose in the form of orange juice. If the symptoms do not resolve immediately, the treatment should be repeated. The client does not need intravenous dextrose, insulin, or glucagon. DIF:Applying/Application

p. 1437 TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Teaching/Learning 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.

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. DIF: Cognitive Level: Application/Applying or higher

1338 KEY: Diabetes mellitus| exercise MSC: Integrated Process: Teaching/Learning NOT:Client Needs Category: Health Promotion and Maintenance 23.A nurse cares for a client who is diagnosed with acute rejection 2 months after receiving a simultaneous pancreas-kidney transplant. 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. How should the nurse respond? a. Following the drug regimen more closely would have prevented this. b. One acute rejection episode does not mean that you will lose the new organs. c. Dialysis is a viable treatment option for you and may save your life. d. Since you are on the national registry, you can receive a second transplantation.

B 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. The client may not be a candidate for additional organ transplantation. DIF:Applying/Application

1181 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 41. A 34-year-old has a new diagnosis of type 2 diabetes. The nurse will discuss the need to schedule a dilated eye exam a. every 2 years. b. as soon as possible. c. when the patient is 39 years old. d. within the first year after diagnosis.

B Because many patients have some diabetic retinopathy when they are first diagnosed with type 2 diabetes, a dilated eye exam is recommended at the time of diagnosis and annually thereafter. Patients with type 1 diabetes should have dilated eye exams starting 5 years after they are diagnosed and then annually. DIF: Cognitive Level: Apply (application)

1.A nurse is teaching a client with diabetes mellitus who asks, Why is it necessary to maintain my blood glucose levels no lower than about 60 mg/dL? How should the nurse respond? 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.

B Because the brain cannot synthesize or store significant amounts of glucose, a continuous supply from the bodys circulation is needed to meet the fuel demands of the central nervous system. The nurse would want to educate the client to prevent hypoglycemia. The body can use other sources of fuel, including fat and protein, and glucose is not involved in the production of red blood cells. Glucose in the blood will encourage glucose metabolism but is not directly responsible for lactic acid formation. DIF:Remembering/Knowledge

p. 1411 TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology) MSC: Integrated Process: Nursing Process (Assessment) 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 nurses 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.

B Because the brain cannot synthesize or store significant amounts of glucose, a continuous supply from the bodys circulation is needed to meet the fuel demands of the central nervous system. The other statements are not accurate. DIF: Cognitive Level: Comprehension/Understanding

1178 OBJ: Special Questions: Multiple Patients; Prioritization TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment 47. After change-of-shift report, which patient should the nurse assess first? a. 19-year-old with type 1 diabetes who has a hemoglobin A1C of 12% b. 23-year-old with type 1 diabetes who has a blood glucose of 40 mg/dL c. 40-year-old who is pregnant and whose oral glucose tolerance test is 202 mg/dL d. 50-year-old who uses exenatide (Byetta) and is complaining of acute abdominal pain

B Because the brain requires glucose to function, untreated hypoglycemia can cause unconsciousness, seizures, and death. The nurse will rapidly assess and treat the patient with low blood glucose. The other patients also have symptoms that require assessments and/or interventions, but they are not at immediate risk for life-threatening complications. DIF: Cognitive Level: Analyze (analysis)

1169 TOP: Nursing Process: Evaluation MSC: NCLEX: Health Promotion and Maintenance 20. The nurse is preparing to teach a 43-year-old man who is newly diagnosed with type 2 diabetes about home management of the disease. Which action should the nurse take first? a. Ask the patients family to participate in the diabetes education program. b. Assess the patients perception of what it means to have diabetes mellitus. c. Demonstrate how to check glucose using capillary blood glucose monitoring. d. Discuss the need for the patient to actively participate in diabetes management.

B Before planning teaching, the nurse should assess the patients interest in and ability to self-manage the diabetes. After assessing the patient, the other nursing actions may be appropriate, but planning needs to be individualized to each patient. DIF: Cognitive Level: Apply (application)

1160-1161 TOP: Nursing Process: Evaluation MSC: NCLEX: Health Promotion and Maintenance 11. Which patient action indicates good understanding of the nurses teaching about administration of aspart (NovoLog) insulin? a. The patient avoids injecting the insulin into the upper abdominal area. b. The patient cleans the skin with soap and water before insulin administration. c. The patient stores the insulin in the freezer after administering the prescribed dose. d. The patient pushes the plunger down while removing the syringe from the injection site.

B Cleaning the skin with soap and water or with alcohol is acceptable. Insulin should not be frozen. The patient should leave the syringe in place for about 5 seconds after injection to be sure that all the insulin has been injected. The upper abdominal area is one of the preferred areas for insulin injection. DIF: Cognitive Level: Apply (application)

N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Teaching/Learning 36. The nurse is teaching a client with diabetes about exercise. Which statement by the client indicates a need for further teaching? a. I wont 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.

B Clients should not exercise if their blood glucose is over 250 mg/dL. The other statements are correct and show good understanding. DIF: Cognitive Level: Application/Applying or higher

1314 KEYiabetes mellitus| insulin| medication safety MSC:Integrated Process: Nursing Process: Planning NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 36.After teaching a client with type 2 diabetes mellitus, the nurse assesses the clients understanding. Which statement made by the client indicates a need for additional teaching? a. I need to have an annual appointment even if my glucose levels are in good control. b. Since my diabetes is controlled with diet and exercise, I must 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.

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 client may develop complications and may need insulin in the future. DIF:Applying/Application

Chart 67-7, p. 1447 TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlHome Safety) MSC: Integrated Process: Teaching/Learning 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 Im depressed? What is the nurses best response? a. Many people with long-term diabetes become depressed after a while. b. Its 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.

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. DIF: Cognitive Level: Application/Applying or higher

1327 KEY: Diabetes mellitus| foot care MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 28.A nurse reviews the medication list of a client with a 20-year history of diabetes mellitus. The client holds up the bottle of prescribed duloxetine (Cymbalta) and states, My cousin has depression and is taking this drug. Do you think Im depressed? How should the nurse respond? a. Many people with long-term diabetes become depressed after a while. b. Its 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. No. Many medications can be used for several different disorders.

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. Duloxetine does not have anti-inflammatory properties. Telling the client that many medications are used for different disorders does not provide the client with enough information to be useful. DIF:Applying/Application

1312 KEYiabetes mellitus| oral antidiabetic agents| medication safety MSC:Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 12.A nurse cares for a client with diabetes mellitus who asks, Why do I need to administer more than one injection of insulin each day? How should the nurse respond? 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. c. A regimen of a single dose of insulin injected each day would require that you eat fewer carbohydrates. d. A single dose of insulin would be too large to be absorbed, predictably putting you at risk for insulin shock.

B Even when a single injection of insulin contains a combined dose of different-acting insulin types, the timing of the actions and the timing of food intake may not match well enough to prevent wide variations in blood glucose levels. One dose of insulin would not be appropriate even if the client decreased carbohydrate intake. Additional injections are not required to allow the client practice with injections, nor will one dose increase the clients risk of insulin shock. DIF:Applying/Application

1172 TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance 21. An unresponsive patient with type 2 diabetes is brought to the emergency department and diagnosed with hyperosmolar hyperglycemic syndrome (HHS). The nurse will anticipate the need to a. give a bolus of 50% dextrose. b. insert a large-bore IV catheter. c. initiate oxygen by nasal cannula. d. administer glargine (Lantus) insulin.

B HHS is initially treated with large volumes of IV fluids to correct hypovolemia. Regular insulin is administered, not a long-acting insulin. There is no indication that the patient requires oxygen. Dextrose solutions will increase the patients blood glucose and would be contraindicated. DIF: Cognitive Level: Apply (application)

N/A TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Nursing Process (Evaluation) 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 nurses 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.

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. DIF: Cognitive Level: Comprehension/Understanding

N/A TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning) MSC: Integrated Process: Nursing Process (Evaluation) 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

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. DIF: Cognitive Level: Comprehension/Understanding

N/A TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Nursing Process (Evaluation) 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

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. DIF: Cognitive Level: Application/Applying or higher

1318 KEYiabetes mellitus| insulin| medication safety MSC:Integrated Process: Teaching/Learning NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 9.A nurse teaches a client with type 2 diabetes mellitus who is prescribed glipizide (Glucotrol). Which statement should the nurse include in this clients teaching? a. Change positions slowly when you get out of bed. b. Avoid taking nonsteroidal anti-inflammatory drugs (NSAIDs). c. If you miss a dose of this drug, you can double the next dose. d. Discontinue the medication if you develop a urinary infection.

B NSAIDs potentiate the hypoglycemic effects of sulfonylurea agents. Glipizide is a sulfonylurea. The other statements are not applicable to glipizide. DIF:Applying/Application

p. 1430 TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesExpected Actions/Outcomes) MSC: Integrated Process: Teaching/Learning 15. Which statement made by a client with type 2 diabetes taking nateglinide (Starlix) indicates understanding of this therapy? a. Ill take this medicine with my meals. b. Ill take this medicine right before I eat. c. Ill take this medicine just before I go to bed. d. Ill take this medicine when I wake up in the morning.

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. DIF: Cognitive Level: Application/Applying or higher

1330 KEYiabetes mellitus| hyperglycemia MSC:Integrated Process: Nursing Process: Evaluation NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation 35.A nurse cares for a client who has diabetes mellitus. The nurse administers 6 units of regular insulin and 10 units of NPH insulin at 0700. At which time should the nurse assess the client for potential problems related to the NPH insulin? a. 0800 b. 1600 c. 2000 d. 2300

B Neutral protamine Hagedorn (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 0800 would be too soon. Checking the client at 2000 and 2300 would be too late. The nurse should check the client at 1600. DIF:Applying/Application

N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialLaboratory Values) MSC: Integrated Process: Teaching/Learning 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.

B Nonsteroidal anti-inflammatory drugs potentiate the hypoglycemic effects of sulfonylurea agents. Glipizide is a sulfonylurea. The other statements are not applicable to glipizide. DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Teaching/Learning 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

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. DIF: Cognitive Level: Comprehension/Understanding

1163 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 33. The nurse is taking a health history from a 29-year-old pregnant patient at the first prenatal visit. The patient reports no personal history of diabetes but has a parent who is diabetic. Which action will the nurse plan to take first? a. Teach the patient about administering regular insulin. b. Schedule the patient for a fasting blood glucose level. c. Discuss an oral glucose tolerance test for the twenty-fourth week of pregnancy. d. Provide teaching about an increased risk for fetal problems with gestational diabetes.

B Patients at high risk for gestational diabetes should be screened for diabetes on the initial prenatal visit. An oral glucose tolerance test may also be used to check for diabetes, but it would be done before the twenty-fourth week. The other actions may also be needed (depending on whether the patient develops gestational diabetes), but they are not the first actions that the nurse should take. DIF: Cognitive Level: Apply (application)

1163 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 24. Which action should the nurse take after a 36-year-old patient treated with intramuscular glucagon for hypoglycemia regains consciousness? a. Assess the patient for symptoms of hyperglycemia. b. Give the patient a snack of peanut butter and crackers. c. Have the patient drink a glass of orange juice or nonfat milk. d. Administer a continuous infusion of 5% dextrose for 24 hours.

B Rebound hypoglycemia can occur after glucagon administration, but having a meal containing complex carbohydrates plus protein and fat will help prevent hypoglycemia. Orange juice and nonfat milk will elevate blood glucose rapidly, but the cheese and crackers will stabilize blood glucose. Administration of IV glucose might be used in patients who were unable to take in nutrition orally. The patient should be assessed for symptoms of hypoglycemia after glucagon administration. DIF: Cognitive Level: Apply (application)

1328 KEY: Diabetes mellitus| neuropathy MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 29.A nurse assesses a client with diabetes mellitus. Which clinical manifestation should alert the nurse to decreased kidney function in this client? a. Urine specific gravity of 1.033 b. Presence of protein in the urine c. Elevated capillary blood glucose level d. Presence of ketone bodies in the urine

B Renal dysfunction often occurs in the client with diabetes. Proteinuria is a result of renal dysfunction. Specific gravity is elevated with dehydration. Elevated capillary blood glucose levels and ketones in the urine are consistent with diabetes mellitus but are not specific to renal function. DIF:Applying/Application

N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Analysis) 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

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. DIF: Cognitive Level: Comprehension/Understanding

1328 KEYiabetes mellitus| renal failure MSC:Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 30.A nurse develops a dietary plan for a client with diabetes mellitus and new-onset microalbuminuria. Which component of the clients diet should the nurse decrease? a. Carbohydrates b. Proteins c. Fats d. Total calories

B Restriction of dietary protein to 0.8 g/kg of body weight per day is recommended for clients with microalbuminuria to delay progression to renal failure. The clients diet does not need to be decreased in carbohydrates, fats, or total calories. DIF:Remembering/Knowledge

p. 1418 TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology) MSC: Integrated Process: Nursing Process (Assessment) 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.

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. DIF: Cognitive Level: Comprehension/Understanding

1307 KEYiabetes mellitus| health screening MSC:Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 8.A nurse teaches a client about self-monitoring of blood glucose levels. Which statement should the nurse include in this clients teaching to prevent bloodborne infections? a. Wash your hands after completing each test. b. Do not share your monitoring equipment. c. Blot excess blood from the strip with a cotton ball. d. Use gloves when monitoring your blood glucose.

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 his or her hands before testing. The client would not need to blot excess blood away from the strip or wear gloves. DIF:Applying/Application

1316 KEYiabetes mellitus| insulin| medication safety MSC:Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 44.A nurse reviews the chart and new prescriptions for a client with diabetic ketoacidosis: Vital Signs and Assessment Laboratory Results Medications Blood pressure: 90/62 mm Hg Pulse: 120 beats/min Respiratory rate: 28 breaths/min Urine output: 20 mL/hr via catheter Serum potassium: 2.6 mEq/L Potassium chloride 40 mEq IV bolus STAT Increase IV fluid to 100 mL/hr Which action should the nurse take? a. Administer the potassium and then consult with the provider about the fluid order. b. Increase the intravenous rate and then consult with the provider about the potassium prescription. c. Administer the potassium first before increasing the infusion flow rate. d. Increase the intravenous flow rate before administering the potassium.

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 and then consult with the provider about the potassium. DIF:Applying/Application

N/A TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication) MSC: Integrated Process: Caring 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.

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 clients level is dangerously low. DIF: Cognitive Level: Application/Applying or higher

1322 KEYiabetes mellitus| nutritional requirements MSC:Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort 41.A nurse reviews laboratory results for a client with diabetes mellitus who is prescribed an intensified insulin regimen: Fasting blood glucose: 75 mg/dL Postprandial blood glucose: 200 mg/dL Hemoglobin A1c level: 5.5% How should the nurse interpret these laboratory findings? a. Increased risk for developing ketoacidosis b. Good control of blood glucose c. Increased risk for developing hyperglycemia d. Signs of insulin resistance

B The client is maintaining blood glucose levels within the defined ranges for goals in an intensified regimen. Because the clients glycemic control is good, he or she is not at higher risk for ketoacidosis or hyperglycemia and is not showing signs of insulin resistance. DIF:Applying/Application

1157 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 38. Which laboratory value reported to the nurse by the unlicensed assistive personnel (UAP) indicates the most urgent need for the nurses assessment of the patient? a. Bedtime glucose of 140 mg/dL b. Noon blood glucose of 52 mg/dL c. Fasting blood glucose of 130 mg/dL d. 2-hr postprandial glucose of 220 mg/dL

B The nurse should assess the patient with a blood glucose level of 52 mg/dL for symptoms of hypoglycemia and give the patient a carbohydrate-containing beverage such as orange juice. The other values are within an acceptable range or not immediately dangerous for a diabetic patient. DIF: Cognitive Level: Apply (application)

1166 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 19. The nurse identifies a need for additional teaching when the patient who is self-monitoring blood glucose a. washes the puncture site using warm water and soap. b. chooses a puncture site in the center of the finger pad. c. hangs the arm down for a minute before puncturing the site. d. says the result of 120 mg indicates good blood sugar control.

B The patient is taught to choose a puncture site at the side of the finger pad because there are fewer nerve endings along the side of the finger pad. The other patient actions indicate that teaching has been effective. DIF: Cognitive Level: Apply (application)

p. 1439 TOP: Client Needs Category: Physiological Integrity (Basic Care and ComfortNutrition and Oral Hydration) MSC: Integrated Process: Teaching/Learning 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

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. DIF: Cognitive Level: Application/Applying or higher

1158 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 15. Which information will the nurse include when teaching a 50-year-old patient who has type 2 diabetes about glyburide (Micronase, DiaBeta, Glynase)? a. Glyburide decreases glucagon secretion from the pancreas. b. Glyburide stimulates insulin production and release from the pancreas. c. Glyburide should be taken even if the morning blood glucose level is low. d. Glyburide should not be used for 48 hours after receiving IV contrast media.

B The sulfonylureas stimulate the production and release of insulin from the pancreas. If the glucose level is low, the patient should contact the health care provider before taking the glyburide, because hypoglycemia can occur with this class of medication. Metformin should be held for 48 hours after administration of IV contrast media, but this is not necessary for glyburide. Glucagon secretion is not affected by glyburide. DIF: Cognitive Level: Apply (application)

1312 KEYiabetes mellitus| oral antidiabetic agents| medication safety MSC:Integrated Process: Nursing Process: Evaluation NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 11.A nurse cares for a client who is prescribed pioglitazone (Actos). After 6 months of therapy, the client reports that his urine has become darker since starting the medication. Which action should the nurse take? a. Assess for pain or burning with urination. b. Review the clients liver function study results. c. Instruct the client to increase water intake. d. Test a sample of urine for occult blood.

B 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 clients most recent liver function studies. The nurse does not need to assess for pain or burning with urination and does not need to check the urine for occult blood. The client does not need to be told to increase water intake. DIF:Applying/Application

1163 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 28. A diabetic patient who has reported burning foot pain at night receives a new prescription. Which information should the nurse teach the patient about amitriptyline (Elavil)? a. Amitriptyline decreases the depression caused by your foot pain. b. Amitriptyline helps prevent transmission of pain impulses to the brain. c. Amitriptyline corrects some of the blood vessel changes that cause pain. d. Amitriptyline improves sleep and makes you less aware of nighttime pain.

B Tricyclic antidepressants decrease the transmission of pain impulses to the spinal cord and brain. Tricyclic antidepressants also improve sleep quality and are used for depression, but that is not the major purpose for their use in diabetic neuropathy. The blood vessel changes that contribute to neuropathy are not affected by tricyclic antidepressants. DIF: Cognitive Level: Apply (application)

N/A TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology) MSC: Integrated Process: Nursing Process (Assessment) 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.

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. DIF: Cognitive Level: Application/Applying or higher

1325 KEYiabetes mellitus| insulin| medication safety MSC:Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation 33.A nurse teaches a client with diabetes mellitus about sick day management. Which statement should the nurse include in this clients teaching? a. When ill, avoid eating or drinking to reduce vomiting and diarrhea. b. Monitor your blood glucose levels at least every 4 hours while sick. c. If vomiting, do not use insulin or take your oral antidiabetic agent. d. Try to continue your prescribed exercise regimen even if you are sick.

B When ill, the client should monitor his or her blood glucose at least every 4 hours. The client should continue taking the medication regimen while ill. The client should continue to eat and drink as tolerated but should not exercise while sick. DIF:Applying/Application

1333 KEYiabetes mellitus| hyperglycemia MSC:Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation 19.A nurse assesses a client who has diabetes mellitus. Which arterial blood gas values should the nurse identify as potential ketoacidosis in this client? 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 7.32, HCO3 22 mEq/L, PCO2 58 mm Hg, PO2 88 mm Hg

B When the lungs can no longer offset acidosis, the pH decreases to below normal. A client who has diabetic ketoacidosis would present with arterial blood gas values that show primary metabolic acidosis with decreased bicarbonate levels and a compensatory respiratory alkalosis with decreased carbon dioxide levels. DIF:Applying/Application

N/A TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology) MSC: Integrated Process: Nursing Process (Assessment) 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

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. DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Evaluation) 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 nurses 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.

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. DIF: Cognitive Level: Application/Applying or higher

p. 1451 TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Alterations in Body Systems) MSC: Integrated Process: Teaching/Learning 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.

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. DIF: Cognitive Level: Application/Applying or higher

p. 1434 TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlSafe Use of Equipment) MSC: Integrated Process: Teaching/Learning 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.

C Carbohydrates are an extremely important source of energy. They should compose at least 45% to 65% of the diabetic persons total caloric intake. The client needs to eat at least 130 g of carbohydrates a day. The other statements show good understanding. DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Teaching/Learning 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

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. DIF: Cognitive Level: Application/Applying or higher

1327 KEYiabetes mellitus| collaboration MSC:Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 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.

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. DIF: Cognitive Level: Knowledge/Remembering

N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Teaching/Learning 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 clients chart. b. Test sensory perception in the clients hands. c. Examine the clients feet for signs of injury. d. Notify the health care provider.

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 clients 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. DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesMedication Administration) MSC: Integrated Process: Nursing Process (Implementation) 1. Which statement by a nurse to a patient newly diagnosed with type 2 diabetes is correct? a. Insulin is not used to control blood glucose in patients with type 2 diabetes. b. Complications of type 2 diabetes are less serious than those of type 1 diabetes. c. Changes in diet and exercise may control blood glucose levels in type 2 diabetes. d. Type 2 diabetes is usually diagnosed when the patient is admitted with a hyperglycemic coma.

C For some patients with type 2 diabetes, changes in lifestyle are sufficient to achieve blood glucose control. Insulin is frequently used for type 2 diabetes, complications are equally severe as for type 1 diabetes, and type 2 diabetes is usually diagnosed with routine laboratory testing or after a patient develops complications such as frequent yeast infections. DIF: Cognitive Level: Understand (comprehension)

1158 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 17. When a patient who takes metformin (Glucophage) to manage type 2 diabetes develops an allergic rash from an unknown cause, the health care provider prescribes prednisone (Deltasone). The nurse will anticipate that the patient may a. need a diet higher in calories while receiving prednisone. b. develop acute hypoglycemia while taking the prednisone. c. require administration of insulin while taking prednisone. d. have rashes caused by metformin-prednisone interactions.

C Glucose levels increase when patients are taking corticosteroids, and insulin may be required to control blood glucose. Hypoglycemia is not a side effect of prednisone. Rashes are not an adverse effect caused by taking metformin and prednisone simultaneously. The patient may have an increased appetite when taking prednisone, but will not need a diet that is higher in calories. DIF: Cognitive Level: Apply (application)

1171-1172 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 23. The health care provider suspects the Somogyi effect in a 50-year-old patient whose 6:00 AM blood glucose is 230 mg/dL. Which action will the nurse teach the patient to take? a. Avoid snacking at bedtime. b. Increase the rapid-acting insulin dose. c. Check the blood glucose during the night d. Administer a larger dose of long-acting insulin.

C If the Somogyi effect is causing the patients increased morning glucose level, the patient will experience hypoglycemia between 2:00 and 4:00 AM. The dose of insulin will be reduced, rather than increased. A bedtime snack is used to prevent hypoglycemic episodes during the night. DIF: Cognitive Level: Apply (application)

1178 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 22. A 26-year-old female with type 1 diabetes develops a sore throat and runny nose after caring for her sick toddler. The patient calls the clinic for advice about her symptoms and a blood glucose level of 210 mg/dL despite taking her usual glargine (Lantus) and lispro (Humalog) insulin. The nurse advises the patient to a. use only the lispro insulin until the symptoms are resolved. b. limit intake of calories until the glucose is less than 120 mg/dL. c. monitor blood glucose every 4 hours and notify the clinic if it continues to rise. d. decrease intake of carbohydrates until glycosylated hemoglobin is less than 7%.

C Infection and other stressors increase blood glucose levels and the patient will need to test blood glucose frequently, treat elevations appropriately with lispro insulin, and call the health care provider if glucose levels continue to be elevated. Discontinuing the glargine will contribute to hyperglycemia and may lead to diabetic ketoacidosis (DKA). Decreasing carbohydrate or caloric intake is not appropriate because the patient will need more calories when ill. Glycosylated hemoglobin testing is not used to evaluate short-term alterations in blood glucose. DIF: Cognitive Level: Apply (application)

N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesExpected Actions/Outcomes) MSC: Integrated Process: Nursing Process (Planning) 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.

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. DIF: Cognitive Level: Application/Applying or higher

Chart 67-11, p. 1456 TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Teaching/Learning 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).

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. DIF: Cognitive Level: Application/Applying or higher

1154 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 39. When a patient with type 2 diabetes is admitted for a cholecystectomy, which nursing action can the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Communicate the blood glucose level and insulin dose to the circulating nurse in surgery. b. Discuss the reason for the use of insulin therapy during the immediate postoperative period. c. Administer the prescribed lispro (Humalog) insulin before transporting the patient to surgery. d. Plan strategies to minimize the risk for hypoglycemia or hyperglycemia during the postoperative period.

C LPN/LVN education and scope of practice includes administration of insulin. Communication about patient status with other departments, planning, and patient teaching are skills that require RN education and scope of practice. DIF: Cognitive Level: Apply (application)

1168 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 8. The nurse determines a need for additional instruction when the patient with newly diagnosed type 1 diabetes says which of the following? a. I can have an occasional alcoholic drink if I include it in my meal plan. b. I will need a bedtime snack because I take an evening dose of NPH insulin. c. I can choose any foods, as long as I use enough insulin to cover the calories. d. I will eat something at meal times to prevent hypoglycemia, even if I am not hungry.

C Most patients with type 1 diabetes need to plan diet choices very carefully. Patients who are using intensified insulin therapy have considerable flexibility in diet choices but still should restrict dietary intake of items such as fat, protein, and alcohol. The other patient statements are correct and indicate good understanding of the diet instruction. DIF: Cognitive Level: Apply (application)

1182 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 42. After the nurse has finished teaching a patient who has a new prescription for exenatide (Byetta), which patient statement indicates that the teaching has been effective? a. I may feel hungrier than usual when I take this medicine. b. I will not need to worry about hypoglycemia with the Byetta. c. I should take my daily aspirin at least an hour before the Byetta. d. I will take the pill at the same time I eat breakfast in the morning.

C Since exenatide slows gastric emptying, oral medications should be taken at least an hour before the exenatide to avoid slowing absorption. Exenatide is injected and increases feelings of satiety. Hypoglycemia can occur with this medication. DIF: Cognitive Level: Apply (application)

1310 KEYiabetes mellitus| oral antidiabetic medications| medication safety MSC:Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 40.After teaching a client who is newly diagnosed with type 2 diabetes mellitus, the nurse assesses the clients understanding. Which statement made by the client indicates a need for additional teaching? a. I should increase my intake of vegetables with higher amounts of dietary fiber. b. My intake of saturated fats should be no more than 10% of my total calorie intake. c. I should decrease my intake of protein and eliminate carbohydrates from my diet. d. My intake of water is not restricted by my treatment plan or medication regimen.

C The client should not completely eliminate carbohydrates from the diet, and should reduce protein if microalbuminuria is present. The client should increase dietary intake of complex carbohydrates, including vegetables, and decrease intake of fat. Water does not need to be restricted unless kidney failure is present. DIF:Applying/Application

1333 KEYiabetes mellitus| medication safety| electrolyte imbalance MSC:Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 45.At 4:45 p.m., a nurse assesses a client with diabetes mellitus who is recovering from an abdominal hysterectomy 2 days ago. The nurse notes that the client is confused and diaphoretic. The nurse reviews the assessment data provided in the chart below: Capillary Blood Glucose Testing (AC/HS) Dietary Intake At 0630: 95 At 1130: 70 At 1630: 47 Breakfast: 10% eaten client states she is not hungry Lunch: 5% eaten client is nauseous; vomits once After reviewing the clients assessment data, which action is appropriate at this time? a. Assess the clients oxygen saturation level and administer oxygen. b. Reorient the client and apply a cool washcloth to the clients forehead. c. Administer dextrose 50% intravenously and reassess the client. d. Provide a glass of orange juice and encourage the client to eat dinner.

C The clients symptoms are related to hypoglycemia. Since the client has not been tolerating food, the nurse should administer dextrose intravenously. The clients oxygen level could be checked, but based on the information provided, this is not the priority. The client will not be reoriented until the glucose level rises. DIF:Applying/Application

1165 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 43. A few weeks after an 82-year-old with a new diagnosis of type 2 diabetes has been placed on metformin (Glucophage) therapy and taught about appropriate diet and exercise, the home health nurse makes a visit. Which finding by the nurse is most important to discuss with the health care provider? a. Hemoglobin A1C level is 7.9%. b. Last eye exam was 18 months ago. c. Glomerular filtration rate is decreased. d. Patient has questions about the prescribed diet.

C The decrease in renal function may indicate a need to adjust the dose of metformin or change to a different medication. In older patients, the goal for A1C may be higher in order to avoid complications associated with hypoglycemia. The nurse will plan on scheduling the patient for an eye exam and addressing the questions about diet, but the biggest concern is the patients decreased renal function. DIF: Cognitive Level: Apply (application)

1177 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 36. A patient who was admitted with diabetic ketoacidosis secondary to a urinary tract infection has been weaned off an insulin drip 30 minutes ago. The patient reports feeling lightheaded and sweaty. Which action should the nurse take first? a. Infuse dextrose 50% by slow IV push. b. Administer 1 mg glucagon subcutaneously. c. Obtain a glucose reading using a finger stick. d. Have the patient drink 4 ounces of orange juice.

C The patients clinical manifestations are consistent with hypoglycemia and the initial action should be to check the patients glucose with a finger stick or order a stat blood glucose. If the glucose is low, the patient should ingest a rapid-acting carbohydrate, such as orange juice. Glucagon or dextrose 50% might be given if the patients symptoms become worse or if the patient is unconscious. DIF: Cognitive Level: Apply (application)

15-16 | 1185 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment 46. After change-of-shift report, which patient will the nurse assess first? a. 19-year-old with type 1 diabetes who was admitted with possible dawn phenomenon b. 35-year-old with type 1 diabetes whose most recent blood glucose reading was 230 mg/dL c. 60-year-old with hyperosmolar hyperglycemic syndrome who has poor skin turgor and dry oral mucosa d. 68-year-old with type 2 diabetes who has severe peripheral neuropathy and complains of burning foot pain

C The patients diagnosis of HHS and signs of dehydration indicate that the nurse should rapidly assess for signs of shock and determine whether increased fluid infusion is needed. The other patients also need assessment and intervention but do not have life-threatening complications. DIF: Cognitive Level: Analyze (analysis)

1323 KEYiabetes mellitus| pancreas-kidney transplant MSC:Integrated Process: Nursing Process: Evaluation NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 25.A nurse assesses a client with diabetes mellitus 3 hours after a surgical procedure and notes the clients breath has a fruity odor. Which action should the nurse take? a. Encourage the client to use an incentive spirometer. b. Increase the clients intravenous fluid flow rate. c. Consult the provider to test for ketoacidosis. d. Perform meticulous pulmonary hygiene care.

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. Using an incentive spirometer, increasing IV fluids, and performing pulmonary hygiene will not address this clients problem. DIF:Applying/Application

1183 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 29. Which information is most important for the nurse to report to the health care provider before a patient with type 2 diabetes is prepared for a coronary angiogram? a. The patients most recent HbA1C was 6.5%. b. The patients admission blood glucose is 128 mg/dL. c. The patient took the prescribed metformin (Glucophage) today. d. The patient took the prescribed captopril (Capoten) this morning.

C To avoid lactic acidosis, metformin should be discontinued a day or 2 before the coronary arteriogram and should not be used for 48 hours after IV contrast media are administered. The other patient data will also be reported but do not indicate any need to reschedule the procedure. DIF: Cognitive Level: Apply (application)

N/A TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology) MSC: Integrated Process: Nursing Process (Analysis) 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

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 clients creatinine level is high. The other findings would not be correlated with declining kidney function. DIF: Cognitive Level: Application/Applying or higher

1322 KEYiabetes mellitus| preoperative nursing MSC:Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 27.A nurse teaches a client with diabetes mellitus who is experiencing numbness and reduced sensation. Which statement should the nurse include in this clients teaching to prevent injury? a. Examine your feet using a mirror every day. b. Rotate your insulin injection sites every week. c. Check your blood glucose level before each meal. d. Use a bath thermometer to test the water temperature.

D Clients with diminished sensory perception can easily experience a burn injury when bathwater 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 checking blood glucose levels will not prevent injury. DIF:Applying/Application

N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlError Prevention) MSC: Integrated Process: Nursing Process (Analysis) 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.

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. DIF: Cognitive Level: Application/Applying or higher

1175 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 18. A hospitalized diabetic patient received 38 U of NPH insulin at 7:00 AM. At 1:00 PM, the patient has been away from the nursing unit for 2 hours, missing the lunch delivery while awaiting a chest x-ray. To prevent hypoglycemia, the best action by the nurse is to a. save the lunch tray for the patients later return to the unit. b. ask that diagnostic testing area staff to start a 5% dextrose IV. c. send a glass of milk or orange juice to the patient in the diagnostic testing area. d. request that if testing is further delayed, the patient be returned to the unit to eat.

D Consistency for mealtimes assists with regulation of blood glucose, so the best option is for the patient to have lunch at the usual time. Waiting to eat until after the procedure is likely to cause hypoglycemia. Administration of an IV solution is unnecessarily invasive for the patient. A glass of milk or juice will keep the patient from becoming hypoglycemic but will cause a rapid rise in blood glucose because of the rapid absorption of the simple carbohydrate in these items. DIF: Cognitive Level: Apply (application)

1319 KEYiabetes mellitus| patient education MSC:Integrated Process: Teaching/Learning NOT:Client Needs Category: Health Promotion and Maintenance 37.When teaching a client recently diagnosed with type 1 diabetes mellitus, the client states, I will never be able to stick myself with a needle. How should the nurse respond? a. I can give your injections to you while you are here in the hospital. b. Everyone gets used to giving themselves injections. It really does not hurt. c. Your disease will not be managed properly if you refuse to administer the shots. d. Tell me what it is about the injections that are concerning you.

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 bad. Stating that you dont know another way to manage the disease is dismissive of the clients concerns. DIF:Applying/Application

N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Nursing Process (Evaluation) 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 nurses 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.

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 dont know another way to manage the disease is dismissive of the clients concerns. DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Teaching/Learning 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

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. DIF: Cognitive Level: Comprehension/Understanding

1301 KEY: Diabetes mellitus| hyperglycemia MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 7.A nurse assesses clients who are at risk for diabetes mellitus. Which client is at greatest risk? a. A 29-year-old Caucasian b. A 32-year-old African-American c. A 44-year-old Asian d. A 48-year-old American Indian

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 this client at highest risk. DIF:Understanding/Comprehension

N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialLaboratory Values) MSC: Integrated Process: Nursing Process (Assessment) 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.

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. DIF: Cognitive Level: Application/Applying or higher

1302 KEYiabetes mellitus| hyperglycemia MSC:Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 3.After teaching a young adult client who is newly diagnosed with type 1 diabetes mellitus, the nurse assesses the clients understanding. Which statement made by the client indicates a correct understanding of the need for eye examinations? a. At my age, I should continue seeing the ophthalmologist as I usually do. b. I will see the eye doctor when I have a vision problem and yearly after age 40. c. My vision will change quickly. I should see the ophthalmologist twice a year. d. Diabetes can cause blindness, so I should see the ophthalmologist yearly.

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. DIF:Applying/Application

p. 1438 TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Teaching/Learning 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.

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. DIF: Cognitive Level: Application/Applying or higher

1315 KEYiabetes mellitus| insulin| medication safety MSC:Integrated Process: Teaching/Learning NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 17.After teaching a client who has diabetes mellitus and proliferative retinopathy, nephropathy, and peripheral neuropathy, the nurse assesses the clients understanding. Which statement made by the client indicates a correct understanding of the teaching? a. I have so many complications; exercising is not recommended. b. I will exercise more frequently because I have so many complications. c. I used to run for exercise; I will start training for a marathon. d. I should look into swimming or water aerobics to get my exercise.

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 should not exercise too vigorously. DIF:Applying/Application

1339 KEYiabetes mellitus| insulin| medication safety MSC:Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation 39.A nurse reviews the medication list of a client recovering from a computed tomography (CT) scan with IV contrast to rule out small bowel obstruction. Which medication should alert the nurse to contact the provider and withhold the prescribed dose? a. Pioglitazone (Actos) b. Glimepiride (Amaryl) c. Glipizide (Glucotrol) d. Metformin (Glucophage)

D Glucophage should not be administered when the kidneys are attempting to excrete IV contrast from the body. This combination would place the client at high risk for kidney failure. The nurse should hold the metformin dose and contact the provider. The other medications are safe to administer after receiving IV contrast. DIF:Applying/Application

p. 1411 TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology) MSC: Integrated Process: Teaching/Learning 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.

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. DIF: Cognitive Level: Knowledge/Remembering

p. 1434 TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesMedication Administration) MSC: Integrated Process: Teaching/Learning 23. A client has a new insulin pump. Which is the nurses 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.

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. DIF: Cognitive Level: Comprehension/Understanding

1316 KEYiabetes mellitus| insulin| medication safety MSC:Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 16.A nurse teaches a client who is prescribed an insulin pump. Which statement should the nurse include in this clients discharge education? a. Test your urine daily for ketones. b. Use only buffered insulin in your pump. c. Store the insulin in the freezer until you need it. d. Change the needle every 3 days.

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. DIF:Applying/Application

1301 KEY: Diabetes mellitus| hypoglycemia MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation 2.A nurse reviews laboratory results for a client with diabetes mellitus who presents with polyuria, lethargy, and a blood glucose of 560 mg/dL. Which laboratory result should the nurse correlate with the clients polyuria? 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

D Hyperglycemia causes hyperosmolarity of extracellular fluid. This leads to polyuria from an osmotic diuresis. The clients serum osmolarity is high. The clients sodium would be expected to be high owing to dehydration. Serum creatinine and urine ketone bodies are not related to the polyuria. DIF:Applying/Application

p. 1412 TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology) MSC: Integrated Process: Nursing Process (Analysis) 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

D Hyperglycemia causes hyperosmolarity of extracellular fluid. This leads to polyuria from an osmotic diuresis. The clients serum osmolarity is high. The clients sodium would be expected to be high owing to dehydration. Urine ketone bodies and serum creatinine are not related to the polyuria. DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesExpected Actions/Outcomes) MSC: Integrated Process: Teaching/Learning 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

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. DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesAdverse Effects/Contraindications/Side Effects/Interactions) MSC: Integrated Process: Nursing Process (Implementation) 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

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. DIF: Cognitive Level: Application/Applying or higher

1330 KEYiabetes mellitus| hypoglycemia MSC:Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 32.A nurse reviews the laboratory results of a client who is receiving intravenous insulin. Which should alert the nurse to intervene immediately? 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

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. DIF:Applying/Application

1163 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 30. Which action by a patient indicates that the home health nurses teaching about glargine and regular insulin has been successful? a. The patient administers the glargine 30 minutes before each meal. b. The patients family prefills the syringes with the mix of insulins weekly. c. The patient draws up the regular insulin and then the glargine in the same syringe. d. The patient disposes of the open vials of glargine and regular insulin after 4 weeks.

D Insulin can be stored at room temperature for 4 weeks. Glargine should not be mixed with other insulins or prefilled and stored. Short-acting regular insulin is administered before meals, while glargine is given once daily. DIF: Cognitive Level: Apply (application)

1320 KEYiabetes mellitus| nutritional requirements MSC:Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort 22.A nurse teaches a client with type 1 diabetes mellitus. Which statement should the nurse include in this clients teaching to decrease the clients insulin needs? a. Limit your fluid intake to 2 liters a day. b. Animal organ meat is high in insulin. c. Limit your carbohydrate intake to 80 grams a day. d. Walk at a moderate pace for 1 mile daily.

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 mellitus. Restricting fluids and eating organ meats will not reduce insulin needs. People with diabetes need at least 130 grams of carbohydrates each day. DIF:Applying/Application

p. 1440 TOP: Client Needs Category: Health Promotion and Maintenance (Aging Process) MSC: Integrated Process: Nursing Process (Assessment) 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

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. DIF: Cognitive Level: Application/Applying or higher

1310 KEYiabetes mellitus| oral antidiabetic agents| medication safety MSC:Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 10.After teaching a client with type 2 diabetes mellitus who is prescribed nateglinide (Starlix), the nurse assesses the clients understanding. Which statement made by the client indicates a correct understanding of the prescribed therapy? a. Ill take this medicine during each of my meals. b. I must take this medicine in the morning when I wake. c. I will take this medicine before I go to bed. d. I will take this medicine immediately before I eat.

D Nateglinide is an insulin secretagogue that is designed to increase meal-related insulin secretion. It should be taken immediately before each meal. The medication should not be taken without eating as it will decrease the clients blood glucose levels. The medication should be taken before meals instead of during meals. DIF:Applying/Application

1160 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 32. The nurse is interviewing a new patient with diabetes who receives rosiglitazone (Avandia) through a restricted access medication program. What is most important for the nurse to report immediately to the health care provider? a. The patients blood pressure is 154/92. b. The patient has a history of emphysema. c. The patients blood glucose is 86 mg/dL. d. The patient has chest pressure when walking.

D Rosiglitazone can cause myocardial ischemia. The nurse should immediately notify the health care provider and expect orders to discontinue the medication. There is no urgent need to discuss the other data with the health care provider. DIF: Cognitive Level: Apply (application)

1184 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 27. Which finding indicates a need to contact the health care provider before the nurse administers metformin (Glucophage)? a. The patients blood glucose level is 174 mg/dL. b. The patient has gained 2 lb (0.9 kg) since yesterday. c. The patient is scheduled for a chest x-ray in an hour. d. The patients blood urea nitrogen (BUN) level is 52 mg/dL.

D The BUN indicates possible renal failure, and metformin should not be used in patients with renal failure. The other findings are not contraindications to the use of metformin. DIF: Cognitive Level: Apply (application)

N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesExpected Actions/Outcomes) MSC: Integrated Process: Nursing Process (Evaluation) 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 nurses best action? a. Apply ice to this area for 20 minutes. b. Document the finding in the clients chart. c. Assess the client for other signs of cellulitis. d. Instruct the client to use a different site for injection.

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. DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesMedication Administration) MSC: Integrated Process: Teaching/Learning 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 nurses 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

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

1338 KEYiabetes mellitus| insulin| psychosocial response MSC:Integrated Process: Caring NOT: Client Needs Category: Psychosocial Integrity 38.A nurse assesses a client with diabetes mellitus who self-administers subcutaneous insulin. The nurse notes a spongy, swelling area at the site the client uses most frequently for insulin injection. Which action should the nurse take? a. Apply ice to the site to reduce inflammation. b. Consult the provider for a new administration route. c. Assess the client for other signs of cellulitis. d. Instruct the client to rotate sites for insulin injection.

D The clients tissue has been damaged from continuous use of the same site. The client should be educated to rotate sites. The damaged tissue is not caused by cellulitis or any type infection, and applying ice may cause more damage to the tissue. Insulin can only be administered subcutaneously and intravenously. It would not be appropriate or practical to change the administration route. DIF:Applying/Application

1156 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 5. A patient with type 2 diabetes is scheduled for a follow-up visit in the clinic several months from now. Which test will the nurse schedule to evaluate the effectiveness of treatment for the patient? a. Urine dipstick for glucose b. Oral glucose tolerance test c. Fasting blood glucose level d. Glycosylated hemoglobin level

D The glycosylated hemoglobin (A1C or HbA1C) test shows the overall control of glucose over 90 to 120 days. A fasting blood level indicates only the glucose level at one time. Urine glucose testing is not an accurate reflection of blood glucose level and does not reflect the glucose over a prolonged time. Oral glucose tolerance testing is done to diagnose diabetes, but is not used for monitoring glucose control once diabetes has been diagnosed. DIF: Cognitive Level: Apply (application)

1163 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 16. The nurse has been teaching a patient with type 2 diabetes about managing blood glucose levels and taking glipizide (Glucotrol). Which patient statement indicates a need for additional teaching? a. If I overeat at a meal, I will still take the usual dose of medication. b. Other medications besides the Glucotrol may affect my blood sugar. c. When I am ill, I may have to take insulin to control my blood sugar. d. My diabetes wont cause complications because I dont need insulin.

D The patient should understand that type 2 diabetes places the patient at risk for many complications and that good glucose control is as important when taking oral agents as when using insulin. The other statements are accurate and indicate good understanding of the use of glipizide. DIF: Cognitive Level: Apply (application)

N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialLaboratory Values) MSC: Integrated Process: Nursing Process (Analysis) 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

D The rapid, deep respiratory efforts of Kussmaul respiration is the bodys 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. DIF: Cognitive Level: Application/Applying or higher

1333 KEYiabetes mellitus| hyperglycemia MSC:Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 20.A nurse cares for a client experiencing diabetic ketoacidosis who presents with Kussmaul respirations. Which action should the nurse take? a. Administration of oxygen via face mask b. Intravenous administration of 10% glucose c. Implementation of seizure precautions d. Administration of intravenous insulin

D The rapid, deep respiratory efforts of Kussmaul respirations are the bodys attempt to reduce the acids produced by using fat rather than glucose for fuel. 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. The client who is in ketoacidosis may not experience any respiratory impairment and therefore does not need additional oxygen. Giving the client glucose would be contraindicated. The client does not require seizure precautions. DIF:Applying/Application

1333 KEYiabetes mellitus| hyperglycemia| respiratory distress/failure MSC:Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation 21.A nurse cares for a client who has type 1 diabetes mellitus. The client asks, Is it okay for me to have an occasional glass of wine? How should the nurse respond? a. Drinking any wine or alcohol will increase your insulin requirements. b. Because of poor kidney function, people with diabetes should avoid alcohol. c. You should not 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.

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. Kidney function is not impacted by alcohol intake. Alcohol is not associated with increased hunger or overeating. DIF:Applying/Application

N/A TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Nursing Process (Implementation) 33. A client with type 1 diabetes asks whether an occasional glass of wine is allowed in the diet. Which is the nurses 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 shouldnt 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.

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. DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialLaboratory Values) MSC: Integrated Process: Nursing Process (Evaluation) 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.

D When ill, the client should monitor his or her blood glucose at least every 4 hours. The other statements are inaccurate. DIF: Cognitive Level: Comprehension/Understanding