Pre Chapter 41: Drug Therapy for Diabetes Mellitus
What instructions would be important to give to a 50-year-old client with type 2 diabetes who has been switched from glyburide , a sulfonylurea, to repaglinide, a meglitinide?
"It stimulates insulin production, so you need to eat soon after taking the medication."
A client with type 1 diabetes has been prescribed 12 units of regular insulin and 34 units of NPH insulin in the morning. How should the nurse explain why two different types of insulin are required to control the client's blood glucose?
"The different onsets and peaks of the two types provide better overall glucose control."
Which HbA1c result would indicate that a client's diabetes is under good control?
7%-Results vary with the laboratory method used for analysis, but in general, levels between 6.5% and 7% indicate good control of diabetes. Results of 10% or greater indicate poor blood glucose control for the last several months.
The nurse is assessing a client who was administered metformin and notes hyperventilation, nausea, and somnolence. The nurse determines which nursing diagnosis should be prioritized for this client?
Altered Breathing Pattern-When taking metformin, the client is at risk for lactic acidosis manifested by unexplained hyperventilation, myalgia, malaise, GI symptoms, or unusual somnolence. Thus, a nursing diagnosis of Altered Breathing Pattern would be most likely.
A female client visits the health care provider's office after routine labs are drawn. The nurse notes that her A1C is 9. How does the nurse interpret this finding?
Client's average blood glucose is above normal.-The American Diabetes Association (ADA) suggests a target A1C of less than 7%. A1C should be measured every 3 to 6 months. An A1C of 9 indicates that the client's average blood glucose is consistently above normal.
The nurse is educating a client who will be adding an injection of pramlintide to his insulin regimen. What information is most important for the nurse to share with this client to ensure safe medication administration?
Do not give pramlintide in the same site where insulin is administered.-Clients who take pramlintide should not be injected into the same site where insulin is administered.
A nurse has determined a client has developed a hypoglycemic reaction. Which interventions should the nurse perform if the client can adequately demonstrate swallowing and gag reflexes?
Give oral fluids or candy.
When reviewing the medication list of a client being seen in the clinic, the nurse notes that the client is receiving glipizide. Based on the nurse's understanding, this drug is used to treat:
Glipizide is an antidiabetic agent with the desired action of lowering the blood glucose level. It is used to treat hyperglycemia. It would worsen, not treat, hypoglycemia, and it has no role in treating abnormal potassium levels (hypokalemia or hyperkalemia).
A man is brought to the emergency department. He is nonresponsive, and his blood glucose level is 32 mg/dL. Which would the nurse expect to be ordered?
Glucagon
Which would a nurse identify as an example of a sulfonylurea?
Glyburide is an example of a sulfonylurea. Metformin is classified as a biguanide. Acarbose and miglitol are alpha-glucosidase inhibitors.
A nurse is preparing to administer insulin to the client. Which interventions should the nurse perform before administering each insulin dose?
Inspect the previous injection site for inflammation.
After teaching a class about the various drugs used to control blood glucose, the instructor determines that the teaching was successful when the class identifies what as a biguanide?
Metformin-Metformin is classified as a biguanide. Miglitol is an alpha-glucosidase inhibitor. Tolbutamide is a first generation sulfonylurea. Glipizide is a second generation sulfonylurea.
The nurse monitoring a client receiving insulin glulisine notices the client has become confused, diaphoretic, and nauseated; and has a blood glucose of 60 mg/dL. Which emergent treatment would the nurse most likely give?
Methods of terminating a hypoglycemic reaction include the administration of one or more of the following: orange or other fruit juice, hard candy or honey, glucose tablets, glucagon, or glucose 10% or 50% IV.
A client is prescribed sitagliptin. The nurse would expect to administer this drug by which route?
Oral
A nurse should take what steps prior to administering insulin glargine (Lantus) to a client?
Prior to administering insulin glargine (Lantus) to a client, the nurse must complete the following pre-administration steps: carefully check the provider's order for the type and dosage of insulin, check the expiration date on the vial, gently rotate the vial between the palms of the hands, and gently tilt end-to-end before withdrawing the insulin, remove all air bubbles from the syringe barrel, and never mix or dilute insulin glargine (Lantus) with any other insulin or solution because the insulin will not be effective.
A student asks the nursing instructor what insulin has the quickest therapeutic effect once administered.
Regular (Humulin R)
A client diagnosed with diabetic ketoacidosis has been admitted to the intensive care unit. The client is prescribed an intravenous insulin drip, so the nurse knows that what type of insulin will be administered?
Regular insulin- (insulin injection) has a rapid onset of action and can be given intravenously. Therefore, it is the insulin of choice during acute situations, such as DKA, severe infection or other illness, and surgical procedures. All the other options are administered subcutaneously.
A client with hyperinsulinism has been prescribed diazoxide. After administration, which adverse reaction should the nurse prioritize?
Tachycardia-The nurse should monitor for tachycardia, congestive heart failure, sodium and fluid retention, hyperglycemia, and glycosuria as the adverse reactions in the client receiving diazoxide drug therapy.
The nurse in the emergency department receives a conscious client following a motor vehicle accident who has no known history of diabetes but whose blood glucose level is 325 mg/dL. What rationale does the nurse provide explaining this elevated blood glucose level?
The client's stress reaction likely caused an increase in blood sugar.
The nurse is conducting a class for newly diagnosed adult diabetic patients. What would the nurse educate the patients about?
The disease-While it would be important to teach the patients about nutrition, the preservation of intact skin and self-care, adults need extensive education about the disease as well as the drug therapy. Warning signs and symptoms should be stressed repeatedly as the adult learns to juggle insulin needs with exercise, stressors, other drug effects, and diet.
As the first-line treatment, a client with type 2 diabetes has tried diet and exercise. When these fail, what may be added as monotherapy or in combination with metformin to control their disease process?
Thiazolidinediones-Thiazolidinediones (TZDs) may be used as monotherapy with diet and exercise or in combination with metformin a sulfonylurea, or an incretin agent (sitagliptin). Repaglinide, a sitagliptin, or an incretin agent are incorrect answers for this question.
The health care provider prescribes glyburide for a client who is a newly diagnosed type 2 diabetic. The nurse knows that this medication produces hypoglycemia by:
increasing insulin secretion from the pancreas.-The hypoglycemic action of glyburide results from the stimulation of pancreatic beta cells, leading to increased insulin secretion.
Insulin is a hormone released by the pancreatic beta cells in response to a rise in glucose levels and what else?
incretins-Insulin is the hormone produced by the pancreatic beta cells of the islets of Langerhans. The hormone is released into circulation when the levels of glucose around these cells rise. It is also released in response to incretins, peptides that are produced in the GI tract in response to food.
Rosiglitazone is being considered for the treatment of diabetes in an adult client. Before the initiation of rosiglitazone therapy, the nurse should review what laboratory work recently drawn?
liver enzymes
Rosiglitazone is being considered for the treatment of diabetes in an adult client. Before the initiation of rosiglitazone therapy, the nurse should review what laboratory work recently drawn?
liver enzymes-Rosiglitazone has been associated with hepatotoxicity and requires monitoring of liver enzymes. Liver function tests (e.g., serum aminotransferase enzymes) should be checked before starting therapy and every 2 months for 1 year, then periodically.
The nurse is caring for a postoperative client whose diabetes has been well controlled on acarbose. The client is not allowed to take anything orally following complications of abdominal surgery and is receiving high-glucose total parenteral nutrition via a central IV line. What medication can the nurse administer intravenously to control the client's blood glucose level?
regular insulin-Only regular insulin can be administered IV. No other insulins or oral antidiabetic medications can be given IV.
A nurse is preparing to administer an insulin that is clear. Which insulin would the nurse likely administer?
short-acting insulin
Which are risk factors for type-2 diabetes that a nurse should recognize in a client?
A nurse should be able to identify all the risk factors for type-2 diabetes in a client. These include: obesity, older age, family history of diabetes, history of gestational diabetes, impaired glucose tolerance, minimal or no physical activity, and race/ethnicity (Black Americans, Hispanic/Latino Americans, Native Americans, and some Asian Americans).
A client receives a dose of insulin lispro at 8 AM. The nurse would be alert for signs and symptoms of hypoglycemia at which time?
Between 8:30 AM and 9:30 AM-With insulin lispro, peak effects would occur in 30 to 90 minutes or between 8:30 AM and 9:30 AM. Regular insulin peaks in 2 to 4 hours, so the nurse would be alert for signs and symptoms of hypoglycemia at this time, which would be between 10 AM and 12 noon. With insulin detemir, peak effects would occur in 6 to 8 hours, or between 2 PM and 4 PM. With NPH insulin, peak effects would occur in 4 to 12 hours, or between 12 noon and 8 PM.
When describing the effects of incretins on blood glucose control to a group of students, which would an instructor include?
Increases insulin release
A nurse at a health care facility is assigned to administer insulin to the patient. Which intervention should the nurse perform before administering each insulin dose?
Inspect the previous injection site for inflammation.-The nurse should check the previous injection site before administering each insulin dose. The injection sites should be rotated to prevent lipodystrophy. Prefilled syringes should not be kept horizontally; they should be kept in a vertical or oblique position to avoid plugging the needle. The nurse checks for symptoms of myalgia or malaise when administration of metformin leads to lactic acidosis. Insulin should be kept at room temperature for administration. Insulin is refrigerated if it needs to be stored for up to three months for later use.
A client's current condition requires rapid reduction of blood sugar levels. Which type of insulin will have the most rapid onset of action?
insulin lispro
A 2-month-old male child is diagnosed with diabetes. His parents are having difficulty measuring 2 units of insulin in the U-100 syringe. What would the nurse expect the health care provider to order?
U-10 (10 units/mL) insulin-Administration of insulin for infants and toddlers who weigh less than 10 kg or require less than 5 units of insulin per day can be difficult because small doses are hard to measure in a U-100 syringe. Use of diluted insulin allows more accurate administration. The most common dilution strength is U-10 (10 units/mL), and a diluent is available from insulin manufacturers for this purpose. Vials of diluted insulin should be clearly labeled and should be discarded after 1 month.
A 59-year-old man with type 2 diabetes is prescribed metformin. When the client returns to the clinic, he reports that he has lost 8 pounds in a month. How should the nurse respond?
"Please continue taking the medication and monitoring your weight. This is an expected outcome of this drug therapy."
A nurse is preparing to administer insulin glargine to a client. What precaution should the nurse take when administering this drug?
Avoid mixing glargine with other insulins.-When administering insulin glargine to the client, the nurse should avoid mixing it with other insulins or solutions. It will precipitate in the syringe when mixed. If glargine is mixed with another solution, it will lose glucose control, resulting in decreased effectiveness of the insulin. Glargine is administered via the subcutaneous route once daily at bedtime. The nurse should not shake the vial vigorously before withdrawing insulin. The vial should be gently rotated between the palms of the hands and tilted gently end to end immediately before withdrawing the insulin. The nurse administers insulin from vials at room temperature. Vials are stored in the refrigerator if they are to be stored for about 3 months for later use.
A client newly diagnosed with type 1 diabetes asks the nurse why the client cannot just take a pill. The nurse would incorporate what knowledge when responding to this client?
Insulin is needed because the beta cells of the pancreas are no longer functioning.-Insulin is needed in type 1 diabetes because the beta cells of the pancreas are no longer functioning. With type 2 diabetes, insulin is produced, but perhaps not enough to maintain glucose control or the insulin receptors are not sensitive enough to insulin.
A 35-year-old client has begun the administration of glyburide for treatment of diabetes mellitus type 2. The nurse caring for this client provides education regarding this medication. Which statement would NOT be an appropriate instruction for this client?
The medication should have a fixed dose which cannot be manipulated.-Manipulating the dosing of glyburide can often reduce the unpleasant reactions. The primary adverse effect associated with glyburide (and the other sulfonylureas) is hypoglycemia. Concomitant alcohol use increases the rate of glyburide metabolism and may cause a disulfiram-like reaction. Administer glyburide before breakfast or the first main meal of the day in order to stimulate insulin production. It is important to caution clients to avoid taking OTC medications and herbal or dietary supplements without first consulting the prescriber.
After reviewing information about different insulin preparations, a nursing student demonstrates understanding of the information when the student identifies which medication as an example of a long-acting insulin?
insulin glargine- Insulin glargine is an example of a long-acting insulin. Insulin lispro and insulin aspart are rapid-acting insulin. Isophane insulin suspension is an intermediate-acting insulin. Reference:
What instructions would be important to give to a 50-year-old client with type 2 diabetes who has been switched from glyburide , a sulfonylurea, to repaglinide, a meglitinide?
"It stimulates insulin production, so you need to eat soon after taking the medication."-Glyburide's onset of action is 2 to 4 hours, and its duration is 24 hours. Repaglinide's onset of action is within 30 minutes, peak is 1 hour, and duration is approximately 3 to 4 hours. Repaglinide is taken 15 to 30 minutes before each meal because it stimulates the pancreas to secrete insulin to correspond to the food intake. If there is no food intake, the person is at risk of hypoglycemia. Glyburide, a sulfonylurea, also stimulates pancreatic cells, but not until 2 to 4 hours after it is taken. Repaglinide is not less potent, it is not more potent, and the two medications are not virtually the same.
A nurse is preparing a teaching session for a client who is prescribed miglitol. The nurse would instruct the client to administer this drug at which time?
Miglitol is given three times a day with the first bite of the meal because food increases absorption. Longer-acting insulins may be given before breakfast or at bedtime depending on the health care provider's instructions. Lispro may be given 15 minutes before or immediately after a meal.
The nurse is preparing to administer insulin glargine to a client. Which actions will the nurse perform when preparing the insulin?
Prior to administering insulin glargine to a client, the nurse must complete the following preadministration steps: carefully check the health care provider's order for the type and dosage of insulin, check the expiration date on the vial, gently rotate the vial between the palms of the hands, gently tilt end to end before withdrawing the insulin, and remove all air bubbles from the syringe barrel. The nurse should never mix or dilute insulin glargine with any other insulin or solution because the insulin will not be effective.
The nurse is discussing diabetes with a group of individuals who are at risk for the disease. Which statement by a participant indicates an understanding of the role of insulin in the disease?
"Insulin assists glucose molecules to enter the cells of muscle and fat tissues."-Insulin appears to activate a process that helps glucose molecules enter the cells of striated muscle and adipose tissue. It also stimulates the synthesis of glycogen by the liver, promotes protein synthesis, and helps the body store fat by preventing its breakdown for energy.
A nurse is assessing a client receiving insulin glargine 20 units at bedtime. The nurse determines the insulin requirement may increase when preparing to administer which new drug?
Corticosteroids (methylprednisolone), estrogens (estradiol), and niacin are among the drugs that can decrease the effect of insulin and require an increase in insulin dosage to control the client's diabetes. Beta blockers and fibrates increase the effect of insulin and thus may require a decrease in the dosage of insulin.
A client diagnosed with diabetic ketoacidosis has been admitted to the intensive care unit. The client is prescribed an intravenous insulin drip, so the nurse knows that what type of insulin will be administered?
Regular-Regular insulin (insulin injection) has a rapid onset of action and can be given intravenously. Therefore, it is the insulin of choice during acute situations, such as DKA, severe infection or other illness, and surgical procedures. All the other options are administered subcutaneously.
The nurse is reviewing a prescription for metformin. The nurse should immediately contact the prescribing health care provider to report a contraindication if the prescription is for which client?
an 82-year-old diagnosed with type 2 diabetes-There is a black box warning against the use of metformin in persons older than 80 years because of the risk for lactic acidosis. Recent surgery, a diagnosis of anorexia, and the use of oral contraceptives do not contraindicate the use of metformin.
A client's current condition requires rapid reduction of blood sugar levels. Which type of insulin will have the most rapid onset of action?
insulin lispro-Insulin lispro has a 15-minute onset of action. NPH, 70/30, and regular insulin have longer onsets of action, a later peak, and a longer duration of action.
A nurse is preparing to administer a rapid-acting insulin. Which medication would the nurse likely administer?
insulin lispro-Insulin lispro is an example of a rapid-acting insulin. Insulin glargine and insulin detemir are long-acting insulin. Isophane insulin suspension is an intermediate-acting insulin.
A nurse is preparing to administer an insulin that is clear. Which insulin would the nurse likely administer?
short-acting insulin-Short-acting or regular insulin and rapid-acting insulin such as lispro, aspart, and glulisine are clear, whereas intermediate-acting (Humulin N and Humulin L) and long-acting (Humulin U) insulins are cloudy. There is no insulin classified as ultra-short insulin.
A client with diabetes is undergoing testing for glycosylated hemoglobin. The nurse instructs the client that this test measures average blood glucose over what time period?
the past 3 or 4 months-Glycosylated hemoglobin measures glucose control over the past 3 to 4 months. When blood glucose levels are high, glucose molecules attach to hemoglobin in the red blood cell. The longer the hyperglycemia lasts, the more glucose binds to the red blood cell and the higher the glycosylated hemoglobin. This binding lasts for the life of the red blood cell (about 4 months) so the other time frames would not be accurate.
The nurse is caring for a client who is taking insulin. The nurse suspects the client is experiencing hypoglycemia when the client displays what signs?
weakness, sweating, and decreased mentation.