Prioritization, delegation, & assignment: Diabetes Mellitus

In the care of a patient with type 2 diabetes, which actions should the nurse delegate to an unlicensed assistive personnel (UAP)? Select all that apply. 1.)Providing the patient with extra packets of artificial sweetener for coffee 2.)Assessing how well the patient's shoes fit 3.)Recording the liquid intake from the patient's breakfast tray 4.)Teaching the patient what to do if dizziness or lightheadedness occurs 5.)Checking and recording the patient's blood pressure 6.)Assisting the patient to ambulate to the bathroom

1,3,5,6 Rationale: Giving the patient extra sweetener, recording oral intake, assisting with ambulation, and checking blood pressure are all within the scope of practice of the UAP. Assessing shoe fit and patient teaching are within the professional nurse's scope of practice.

The nurse is caring for an 81-year-old adult with type 2 diabetes, hypertension, and peripheral vascular disease. Which admission assessment findings increase the patient's risk for development of hyperglycemic-hyperosmolar syndrome (HHS)? Select all that apply. 1.)Hydrochlorothiazide (HCTZ) prescribed to control her blood pressure 2.)Weight gain of 6 lb (2.7 kg) over the past month 3.)Avoids consuming liquids in the evening 4.)Blood pressure of 168/94 mm Hg 5.)Urine output of 50 to 75 mL/hr 6.)Glucose greater than 600 mg/dL (33.3 mmol/L)

1,3,6 Rationale: HHS often occurs in older adults with type 2 diabetes. Risk factors include taking diuretics and inadequate fluid intake. Serum glucose is greater than 600 mg/dL (33.3 mmol/L). Weight loss (not weight gain) would be a symptom. Although the patient's blood pressure is high, this is not a risk factor. A urine output of 50 to 75 mL/hr is adequate.

Which actions can the school nurse delegate to an experienced unlicensed assistive personnel (UAP) who is working with a 7-year-old child with type 1 diabetes in an elementary school? Select all that apply. 1.)Obtaining information about the child's usual insulin use from the parents 2.)Administering oral glucose tablets when blood glucose level falls below 60 mg/dL (3.3 mmol/L) 3.)Teaching the child about what foods have high carbohydrate levels 4.)Obtaining blood glucose readings using the child's blood glucose monitor 5.)Reminding the child to have a snack after the physical education class 6.)Assessing the child's knowledge level about his or her type 1 diabetes

2,4,5 Rationale: National guidelines published by the American Diabetes Association (ADA) indicate that administration of emergency treatment for hypoglycemia (e.g., glucose tablets), obtaining blood glucose readings, and reminding children about content they have already been taught by licensed caregivers are appropriate tasks for non-health care professional personnel such as teachers, paraprofessionals, and UAP. Assessments and education require more specialized education and scope of practice and should be done by the school nurse.

The RN is the preceptor for a senior nursing student who will teach a patient with diabetes about self-care during sick days. For which statement by the student must the RN intervene? 1.)"When you are sick, be sure to monitor your blood glucose at least every 4 hours." 2.)"Test your urine for ketones whenever your blood glucose level is less than 240 mg/dL (13.3 mmol/L)." 3.)"To prevent dehydration, drink 8 ounces (236 mL) of sugar-free liquid every hour while you are awake." 4.)"Continue to eat your meals and snacks at the usual times."

2.)"Test your urine for ketones whenever your blood glucose level is less than 240 mg/dL (13.3 mmol/L)." Rationale: Urine ketone testing should be done whenever the patient's blood glucose is greater than 240 mg/dL (13.3 mmol/L). All of the other teaching points are appropriate "sick day rules." For dehydration, teaching should also include that if the patient's blood glucose is lower than her target range, she should drink fluids containing sugar.

While the RN is performing an admission assessment on a patient with type 2 diabetes, the patient states that he routinely drinks 3 beers a day. What is the nurse's priority follow-up question at this time? 1.)"Do you have any days when you do not drink?" 2.)"When during the day do you drink your beers?" 3.)"Do you drink any other forms of alcohol?" 4.)"Have you ever had a lipid profile completed?"

2.)"When during the day do you drink your beers?" Rationale: Alcohol has the potential for causing alcohol-induced hypoglycemia. It is important to know when the patient drinks alcohol and to teach the patient to ingest it shortly after meals to prevent this complication. The other questions are important but not urgent. The lipid profile question is important because alcohol can raise plasma triglycerides but is not as urgent as the potential for hypoglycemia.

A patient with diabetes has hot, dry skin; rapid and deep respirations; and a fruity odor to his breath. The charge nurse observes a newly graduated RN performing all the following patient tasks. Which action requires that the charge nurse intervene immediately? 1.)Checking the patient's fingerstick glucose level 2.)Encouraging the patient to drink orange juice 3.)Checking the patient's order for sliding-scale insulin dosing 4.)Assessing the patient's vital signs every 15 minutes

2.)Encouraging the patient to drink orange juice Rationale: The signs and symptoms the patient is exhibiting are consistent with hyperglycemia. The RN should not give the patient additional glucose. All of the other interventions are appropriate for this patient. The RN should also notify the health care provider at this time.

A patient has newly diagnosed type 2 diabetes. Which action should the RN assign to an LPN/LVN rather than an experienced unlicensed assistive personnel (UAP)? 1.)Measuring the patient's vital signs every shift 2.)Checking the patient's glucose level before each meal 3.)Administering subcutaneous insulin on a sliding scale as needed 4.)Assisting the patient with morning care

3.)Administering subcutaneous insulin on a sliding scale as needed Rationale: The UAP's scope of practice includes checking vital signs and assisting with morning care. Experienced UAPs with special training can check the patient's glucose level before meals and at bedtime. It is generally not within the UAP's scope of practice to administer medications, but this is within the scope of practice of the LPN/LVN.

The nurse is preparing to review a teaching plan for a patient with type 2 diabetes mellitus. To determine the patient's level of compliance with his prescribed diabetic regimen, which value would the nurse be sure to review? 1.)Fasting glucose level 2.)Oral glucose tolerance test results 3.)Glycosylated hemoglobin (HgbA1c) level 4.)Fingerstick glucose findings for 24 hours

3.)Glycosylated hemoglobin (HgbA1c) level Rationale: The higher the blood glucose level is over time, the more glycosylated the hemoglobin becomes. The HgbA1c level is a good indicator of the average blood glucose level over the previous 120 days. Fasting glucose and oral glucose tolerance tests are important diagnostic tools. Fingerstick blood glucose monitoring provides information that allows adjustment of the patient's therapeutic regimen.

A patient has newly-diagnosed type 2 diabetes. Which task should the RN delegate to an experienced unlicensed assistive personnel (UAP)? 1.) Arranging a consult with the dietitian 2.)Assessing the patient's insulin injection technique 3.)Teaching the patient to use a glucometer to monitor glucose at home 4.)Checking the patient's glucose level before each meal

4.)Checking the patient's glucose level before each meal Rationale: The experienced UAP would have been taught to perform tasks such as checking pulse oximetry and glucose checks, and these actions would be part of his or her scope of practice. Arranging for a consult with the dietitian is appropriate for the unit clerk. Teaching and assessing require additional education and should be carried out by licensed nurses.

The RN is serving as preceptor to a new graduate nurse who has recently passed the RN licensure (NCLEX®) examination. The new nurse has only been on the unit for 2 days. Which patient should be assigned to the new graduate nurse? 1.) A 68-year-old patient with diabetes who is showing signs of hyperglycemia 2.)A 58-year-old patient with diabetes who has cellulitis of the left ankle 3.)A 49-year-old patient with diabetes just returned from the postanesthesia care unit after a below-knee amputation 4.)A 72-year-old patient with diabetes with diabetic ketoacidosis who is receiving IV insulin

2.)A 58-year-old patient with diabetes who has cellulitis of the left ankle Rationale: The new nurse is very early in orientation to the unit. Appropriate patient assignments at this time include patients whose conditions are stable and not complex. Patients 1, 3, and 4 are more complex and will benefit from care by a nurse experienced in care of patients with diabetes.

A patient with newly diagnosed diabetes has peripheral neuropathy. Which key points should the nurse include in the teaching plan for this patient? Select all that apply. 1.)"Clean and inspect your feet every day." 2.)"Be sure that your shoes fit properly." 3.)"Nylon socks are best to prevent friction on your toes from shoes." 4.)"Only a podiatrist should trim your toenails." 5.)"Report any non-healing skin breaks to your health care provider (HCP)." 6.)"Use a thermometer to check the temperature of water before taking a bath."

1,2,5,6 Rationale: Sensory alterations are the major cause of foot complications in patient with diabetes, and patients should be taught to examine their feet on a daily basis. Properly fitted shoes protect the patient from foot complications. Broken skin increases the risk of infection. Cotton socks are recommended to absorb moisture. Using a bath thermometer can prevent burn injuries. Patients, family, or HCPs may trim toenails.

A 58-year-old patient with type 2 diabetes was admitted to the acute care unit with a diagnosis of chronic obstructive pulmonary disease (COPD) exacerbation. When the RN prepares a care plan for this patient, what would he or she be sure to include? Select all that apply. 1.)Fingerstick blood glucose checks before meals and at bedtime 2.)Sliding-scale insulin dosing as prescribed 3.)Bed rest until the COPD exacerbation is resolved 4.)Teaching about the Atkins diet for weight loss 5.)Demonstration of the components of foot care 6.)Discussing the relationship between illness and glucose levels

1,2,5,6 Rationale: When a patient with diabetes is ill, glucose levels become elevated, and administration of insulin may be necessary. Administration of sliding-scale insulin is guided by fingerstick blood glucose checks. Teaching or reviewing the components of proper foot care is always a good idea with a patient with diabetes. Bed rest is not necessary, and glucose levels may be better controlled when a patient is more active. The Atkins diet recommends decreasing the consumption of carbohydrates and is not a good diet for patient with diabetes.

The unlicensed assistive personnel reports to the RN that a patient with type 1 diabetes has a question about exercise. What important points would the RN be sure to teach this patient? Select all that apply. 1.)Exercise guidelines are based on blood glucose and urine ketone levels. 2.)Be sure to test your blood glucose only after exercising. 3.)You can exercise vigorously if your blood glucose is between 100 and 250 mg/dL (5.6 and 13.9 mmol/L). 4.)Exercise will help resolve the presence of ketones in your urine. 5.)A 5- to 10-minute warm-up and cool-down period should be included in your exercise. 6.)For unplanned exercise, increased intake of carbohydrates is usually needed.

1,3,5,6 Rationale: Guidelines for exercise are based on blood glucose and urine ketone levels. Patients should test blood glucose before, during, and after exercise to be sure that it is safe to exercise. When ketones are present in urine, the patient should not exercise because ketones indicate that current insulin levels are not adequate. Vigorous exercise is permitted in patients with type 1 diabetes if glucose levels are between 100 and 250 mg/dL (5.6 and 13.9 mmol/L). Warm-up and cool-down should be included in exercise to gradually increase and decrease the heart rate. For planned exercise, reduction in insulin dosage is used for hypoglycemia prevention. For unplanned exercise, intake of additional carbohydrate is usually needed.

The nurse is caring for an older patient with type 1 diabetes and diabetic retinopathy. What is the nurse's priority concern for assessing this patient? 1.)Assess ability to measure and inject insulin and to monitor blood glucose levels. 2.) Assess for damage to motor fibers, which can result in muscle weakness. 3.) Assess which modifiable risk factors can be reduced. 4.) Assess for albuminuria, which may indicate kidney disease.

1.) Assess ability to measure and inject insulin and to monitor blood glucose levels. Rationale: The older patient with diabetic retinopathy also has general age-related vision changes, and the ability to perform self-care may be seriously affected. He or she may have blurred vision, distorted central vision, fluctuating vision, loss of color perception, and mobility problems resulting from loss of depth perception. When a patient has visual changes, it is especially important to assess his or her ability to measure and inject insulin and to monitor blood glucose levels to determine if adaptive devices are needed to assist in self-management. The other options are important but are not specific to diabetic retinopathy.

An LPN/LVN is assigned to administer rapid-acting insulin, lispro, to a patient with type 1 diabetes. What essential information would the RN be sure to tell the LPN/LVN? 1.) Give this insulin when the food tray has been delivered and the patient is ready to eat. 2.) Only give this insulin for fingerstick glucose reading is above 200 mg/dL (11.1 mmol/L). 3.) This insulin mimics the basal glucose control of the pancreas. 4.) Rapid-acting insulin is the only insulin that can be given subcutaneously or IV.

1.) Give this insulin when the food tray has been delivered and the patient is ready to eat. Rationale: The onset of action for rapid-acting insulin is within minutes, so it should be given only when the patient has food and is ready to eat. Because of this, rapid-acting insulin is sometimes called "see food" insulin. Options 2, 3, and 4 are incorrect with regard to rapid-acting insulin. Option 2 is incorrect with regard to all forms of insulin. Long-acting insulins mimic the action of the pancreas. Regular insulin is the only insulin that can be given IV.

The nurse is caring for a patient with diabetes who is developing diabetic ketoacidosis (DKA). Which task delegation or assignment is most appropriate? 1.)Ask the unit clerk to page the health care provider to come to the unit. 2.)Ask the LPN/LVN to administer IV push insulin according to a sliding scale. 3.)Ask the unlicensed assistive personnel (UAP) to hang a new bag of normal saline 4.)Ask the UAP to get the patient a cup (236 mL) of orange juice.

1.)Ask the unit clerk to page the health care provider to come to the unit. Rationale: The nurse should not leave the patient. The scope of the unit clerk's job includes calling and paging physicians. LPNs/LVNs generally do not administer IV push medication, although in some states with additional training, this may be done. (Be sure to check the Scope of Practice in your specific state.) IV fluid administration is not within the scope of practice of UAPs. Patients with DKA already have a high glucose level and do not need orange juice.

The plan of care for a patient with diabetes includes all of these interventions. Which intervention should the nurse delegate to unlicensed assistive personnel (UAP)? 1.)Reminding the patient to put on well-fitting shoes before ambulating 2.)Discussing community resources for diabetic outpatient care 3.)Teaching the patient to perform daily foot inspection 4.)Assessing the patient's technique for drawing insulin into a syringe

1.)Reminding the patient to put on well-fitting shoes before ambulating Rationale: Reminding the patient to put on well-fitting shoes (after the nurse has taught the patient about the importance of this action) is part of assisting with activities of daily living and is within the education and scope of practice of the UAP. It is a safety measure that can prevent injury. Discussing community resources, teaching, and assessing require a higher level of education and are appropriate to the scope of practice of licensed nurses.

The nurse is responsible for the care of a patient with diabetes who is unable to swallow, is unconscious and seizing, and has a blood glucose of less than 20 mg/dL (1.1 mmol/L). Which actions are most appropriate responses for this patient at this time? Select all that apply. 1.)Check the chart for the patient's most recent A1c level. 2.)Give glucagon 1 mg subcutaneously or intramuscularly (IM). 3.)Repeat the dose of glucagon in 10 minutes if the patient remains unconscious. 4.)Apply aspiration precautions because glucagon can cause vomiting. 5.)Give the patient an oral simple sugar or snack. 6.)Notify the health care provider (HCP) immediately.

2,3,4,6 Rationale: This patient's manifestations suggest severe hypoglycemia. Essential actions at this time include notifying the HCP immediately and giving glucagon 1 mg subcutaneously or IM. Glucagon is the main counterregulatory hormone to insulin and is used as first-line therapy for severe hypoglycemia in patients with diabetes. The dose or glucagon is repeated after 10 minutes if the patient remains unconscious. Aspiration precautions are important because this drug can cause vomiting. Checking the patient's A1c level is not important at this time. Offering oral glucose or a snack when a patient is unable to swallow or unconscious is inappropriate.

In the emergency department, during initial assessment of a newly admitted patient with diabetes, the nurse discovers all of these findings. Which finding should be reported to the health care provider immediately? 1.)Hammer toe of the left second metatarsophalangeal joint 2.)Rapid respiratory rate with deep inspirations 3.)Numbness and tingling bilaterally in the feet and hands 4.)Decreased sensitivity and swelling of the abdomen

2.)Rapid respiratory rate with deep inspirations Rationale: Rapid, deep respirations (Kussmaul respirations) are symptomatic of diabetic ketoacidosis. Hammer toe, as well as numbness and tingling, are chronic complications associated with diabetes. Decreased sensitivity and swelling (lipohypertrophy) occur at a site of repeated insulin injections, and treatment involves teaching the patient to rotate injection sites within one anatomic site.

An older patient with type 2 diabetes has cardiovascular autonomic neuropathy (CAN). Which instruction would the nurse provide for the unlicensed assistive personnel (UAP) assisting the patient with morning care? 1.)Provide a complete bed bath for this patient. 2.)Sit the patient up slowly on the side of the bed before standing. 3.)Only let the patient wash his or her face and brush his or her teeth. 4.)Be sure to provide rest periods between activities.

2.)Sit the patient up slowly on the side of the bed before standing. Rationale: CAN affects sympathetic and parasympathetic nerves of the heart and blood vessels. It may lead to orthostatic (postural) hypotension and syncope (brief loss of consciousness on standing) caused by failure of the heart and arteries to respond to position changes by increasing heart rate and vascular tone. The nurse should be sure to instruct the UAP to have the patient change positions slowly when moving from lying to sitting and standing.

An LPN/LVN is assigned to perform assessments on two patients with diabetes. Assessments reveals all of these findings. Which finding would the RN instruct the LPN/LVN to report immediately? 1.) Fingerstick glucose reading of 185 mg/dL (10.3 mmol/L) 2.)Numbness and tingling in both feet 3.)Profuse perspiration 4.)Bunion on the left great toe

3.)Profuse perspiration Rationale: Profuse perspiration is a symptom of hypoglycemia, a complication of diabetes that requires urgent treatment. A glucose level of 185 mg/dL (10.3 mmol/L) will need coverage with sliding-scale insulin, but this is not urgent. Numbness and tingling, as well as bunions, are related to the chronic nature of diabetes and are not urgent problems.

An unlicensed assistive personnel (UAP) tells the nurse that while assisting with the morning care of a postoperative patient with type 2 diabetes who has been given insulin, the patient asked if she will always need to take insulin now. What is the RN's priority for teaching the patient? 1.) Explain to the patient that she is now considered to have type 1 diabetes. 2.)Tell the patient to monitor fingerstick glucose level every 4 hours after discharge. 3.)Teach the patient that a person with type 2 diabetes does not always need insulin. 4.)Discuss the relationship between illness and increased glucose levels.

4.)Discuss the relationship between illness and increased glucose levels. Rationale: When a patient with diabetes is ill or has surgery, glucose levels become elevated, and administration of insulin may be necessary. This is a temporary change that usually resolves with recovery from the illness or surgery. Option 3 is correct but does not explain why the patient may currently need insulin. The patient does not have type 1 diabetes, and fingerstick glucose checks are usually prescribed for before meals and at bedtime.

The experienced unlicensed assistive personnel (UAP) has been delegated to take vital signs and check fingerstick glucose on a postoperative patient with diabetes. Which vital sign change would the RN instruct the UAP to report immediately? 1.)Blood pressure increase from 132/80 to 138/84 mm Hg 2.)Temperature increase from 98.4°F to 99°F (36.9°C to 37.2°C) 3.)Respiratory rate increase from 18 to 22 breaths/min 4.)Glucose increase from 190 to 236 mg/dL (10.6 to 13.1 mmol/L)

4.)Glucose increase from 190 to 236 mg/dL (10.6 to 13.1 mmol/L) Rationale: An unexpected rise in blood glucose is associated with increased mortality and morbidity after surgical procedures. American Diabetes Association guidelines recommend insulin protocols to maintain blood glucose levels between 140 and 180 mg/dL (7.8 and 10 mmol/L). Also, unexpected rises in blood glucose values may indicate wound infection.

While working in the diabetes clinic, the RN obtains the following information about an 8-year-old patient with type 1 diabetes. Which finding is most important to address when planning child and parent education? 1.)Most recent hemoglobin A1c level of 7.8% 2.)Many questions about diet choices from the parents 3.)Child's participation in soccer practice after school 2 days a week 4.)Morning preprandial glucose range of 55 to 70 mg/dL (3.1 to 3.9 mmol/L)

4.)Morning preprandial glucose range of 55 to 70 mg/dL (3.1 to 3.9 mmol/L) Rationale: The low morning fasting blood glucose level indicates possible nocturnal hypoglycemia. Research indicates that it is important to avoid hypoglycemic episodes in pediatric patients because of the risk for permanent neurologic damage and adverse developmental outcomes. Although a lower hemoglobin A1c might be desirable, the upper limit for hemoglobin A1c levels ranges from 7.5% to 8.5% in pediatric patients. The parents' questions about diet and the child's activity level should also be addressed, but the most urgent consideration is education about the need to avoid

A patient with type 1 diabetes reports feeling dizzy. What should the nurse do first? 1.)Check the patient's blood pressure. 2.)Give the patient some orange juice. 3.)Give the patient's morning dose of insulin. 4.)Use a glucometer to check the patient's glucose level.

4.)Use a glucometer to check the patient's glucose level. Rationale: Before orange juice or insulin is given, the patient's blood glucose level should be checked. Checking blood pressure is a good idea but is not the first action the nurse should take.