DKA Main
The elderly patient with type 2 diabetes mellitus presents to the clinic with a fever and productive cough. The diagnosis of pneumonia is made. You notice tenting skin, deep tongue furrows, and vital signs of 110/80 mm Hg, 120 beats/minute, and 24 breaths/minute. What assessment is important for you to obtain? A. Blood glucose B. Orthostatic blood pressures C. Urine ketones D. Temperature
A. Blood glucose HHS is typically seen in patients with type 2 diabetes and infection, such as pneumonia. The main presenting sign is a glucose level above 600 mg/dL. Enough evidence of dehydration already exists that orthostatic vital sign assessments are not a priority, and they are often inaccurate in the elderly due to poor vascular tone. Patients with HHS do not have elevated ketone levels, which is a key distinction between HHS and DKA. Temperature will eventually be taken but is often blunted in the elderly and diabetics. An infectious diagnosis has already been made. The glucose level for appropriate fluid and insulin treatment is the priority.
A patient comes to the emergency department with a complaint of nausea, vomiting, and abdominal pain. She is a type 1 diabetic. Four days earlier, she reduced her insulin dose due to flu symptoms and decreased nutritional intake. The nurse performs an assessment of the patient that reveals poor skin turgor, dry mucous membranes, kussmaul respirations, and fruity breath odor. The nurse prioritizes which of the following interventions? Select all that apply. A. Fluid replacement B. IV Regular Insulin C. chest x-ray and bronchoscopy D. Monitor electrolytes and blood glucose levels closely during therapy
A. Fluid replacement B. IV Regular Insulin D. Monitor electrolytes and blood glucose levels closely during therapy
Laboratory results are available for a 54-year-old patient with a 15-year history of diabetes. Which result follows the expected pattern accompanying macrovascular disease as a complication of diabetes? A. Increased triglyceride levels B. Decreased low-density lipoprotein levels C. Increased high-density lipoprotein levels D. Decreased very-low-density lipoprotein levels
A. Increased triglyceride levels Macrovascular complications of diabetes include changes in medium- and large-sized blood vessels. They include cerebrovascular, cardiovascular, and peripheral vascular disease. Increased triglyceride levels are associated with these macrovascular changes. For this reason, the patient should limit the amount of fat in the diet.
A client is admitted to the hospital with a diagnosis of diabetic ketoacidosis. What is the initial intervention the nurse should expect the primary healthcare provider to prescribe for this client? A. Intravenous (IV) fluids B. Potassium C. NPH insulin (Novolin N) D. Sodium polystyrene sulfonate (Kayexalate)
A. Intravenous (IV) fluids IV fluids are given to combat dehydration in ketoacidosis and to keep an IV line open for administration of medications. After electrolyte levels are evaluated, potassium may be added along with insulin. In acidosis, potassium ions initially shift from the intracellular to extracellular compartment, resulting in hyperkalemia; as acidosis is corrected, hypokalemia may occur, and then potassium may be administered. NPH insulin is an intermediate-acting insulin; rapid-acting insulin is indicated in an emergency. Sodium polystyrene sulfonate is not indicated; abnormally high serum potassium levels will revert once dehydration is corrected.
After assessing a client, a nurse concludes that the client may be experiencing hyperglycemia. Which clinical findings commonly associated with hyperglycemia support the nurse's conclusion? Select all that apply. A. Polyuria B. Polydipsia C. Polyphagia D. Polyphrasia E. Polydysplasia
A. Polyuria B. Polydipsia C. Polyphagia Polyuria is excessive urination associated with osmotic diuresis. Polydipsia is excessive thirst associated with hyperglycemia; thirst is the response to osmotic diuresis and glycosuria. Polyphagia is associated with the catabolic state induced by insulin deficiency. Polyphrasia is excessive talking associated with mental illness, not hyperglycemia. Polydysplasia is related to multiple developmental abnormalities and is unrelated to hyperglycemia.
What therapies are appropriate for patients with diabetes mellitus (select all that apply)? A. Use of statins to treat dyslipidemia B. Use of diuretics to treat nephropathy C. Use of angiotensin-converting enzyme (ACE) inhibitors to treat nephropathy D. Use of laser photocoagulation to treat retinopathy E. Use of protein restriction in patients with early signs of nephropathy
A. Use of statins to treat dyslipidemia C. Use of angiotensin-converting enzyme (ACE) inhibitors to treat nephropathy D. Use of laser photocoagulation to treat retinopathy In patients with diabetes who have microalbuminuria or macroalbuminuria, ACE inhibitors (-prils) or angiotensin II receptor antagonists (ARBs) (-sartans) should be used. Both of these drug classes are used to treat hypertension. The statin drugs are the most widely used lipid-lowering drugs. Laser photocoagulation therapy is indicated to reduce the risk of vision loss in patients with proliferative retinopathy, macular edema, and in some cases of nonproliferative retinopathy.
23. As a patient with diabetic ketoacidosis receives insulin and fluids, the nurse knows careful assessment must be given to which of the following electrolytes? A. Potassium B. Sodium C. Phosphorus D. Calcium
ANS A Potassium Replacement of potassium by administration of potassium chloride (KCl) begins as soon as the serum potassium falls below normal. Frequent verification of the serum potassium concentration is required for the patient with diabetic ketoacidosis receiving fluid resuscitation and insulin therapy.
10. A patient has a 10-year history of diabetes mellitus. The patient is admitted to the critical care unit with complaints of increased lethargy. Serum laboratory values validate the diagnosis of diabetic ketoacidosis (DKA). The treatment of DKA involves A. extensive hydration. B. oral hypoglycemic agents. C. large doses of IV insulin. D. limiting food and fluids.
ANS A extensive hydration. Rapid IV fluid replacement requires the use of a volumetric pump. Insulin is administered intravenously to patients who are severely dehydrated or have poor peripheral perfusion to ensure effective absorption. Patients with DKA are kept on NPO (nothing by mouth) status until the hyperglycemia is under control. Critical care nurses are responsible for monitoring the rate of plasma glucose decline in response to insulin.
15. The nurse knows that the dehydration associated with diabetic ketoacidosis results from A. increased serum osmolality and urea. B. decreased serum osmolality and hyperglycemia. C. ketones and potassium shifts. D. acute renal failure.
ANS A increased serum osmolality and urea. Hyperglycemia increases the plasma osmolality, and the blood becomes hyperosmolar. Cellular dehydration occurs as the hyperosmolar extracellular fluid draws the more dilute intracellular and interstitial fluid into the vascular space in an attempt to return the plasma osmolality to normal. 16. The nurse knows that the dehydration in diabetic ketoacidosis stimulates catecholamine release, which results in A. decreased glucose release. B. increased insulin release. C. decreased cardiac contractility. D. increased gluconeogenesis. =ANS D Dehydration stimulates catecholamine production in an effort to provide emergency support. Catecholamine output stimulates further glycogenolysis, lipolysis, and gluconeogenesis, pouring glucose into the bloodstream.
28. To assist the nurse in evaluating the patient's hydration status, assessment would include A. orthostatic hypotension and neck vein filling. B. pupil checks and Kernig sign. C. Chvostek and Trousseau signs. D. S4 gallop and edema.
ANS A orthostatic hypotension and neck vein filling. Assessment for orthostatic hypotension and neck vein filling is an important way to evaluate hydration status.
3. The primary intervention for hyperglycemic hyperosmolar syndrome (HHS) is A. rapid rehydration. B. monitoring vital signs. C. high-dose intravenous (IV) insulin. D. hourly urine sugar and acetone testing.
ANS A rapid rehydration. The goals of medical management are rapid rehydration, insulin replacement, and correction of electrolyte abnormalities, specifically potassium replacement. The underlying stimulus of HHS must be discovered and treated. The same basic principles used to treat patients with diabetic ketoacidosis are used for patients with HHS.
22. A nondiabetic patient presents ketoacidosis. Reasons may include A. starvation and alcoholism. B. drug overdose. C. severe vomiting. D. hyperaldosteronism.
ANS A starvation and alcoholism. Other nondiabetic causes of ketoacidosis are starvation ketosis and alcoholic ketoacidosis.
48. The neuroendocrine stress response produces which of the following? (Select all that apply.) A. Elevated blood pressure B. Decreased gastric motility C. Tachycardia D. Heightened pain awareness E. Increased glucose
ANS A, B, C, E A. Elevated blood pressure B. Decreased gastric motility C. Tachycardia E. Increased glucose The fight-or-flight response, or sympathetic nervous response, releases catecholamine that causes an increased heart rate and blood pressure. Blood is shunted form nonessential organs such as the stomach, glucose is made available to the brain cells, and pain awareness is decreased.
49. A patient was admitted to the critical care unit with diabetic ketoacidosis (DKA). Glucose is 349 mg/dL, K is 3.7 mEq/L, and pH is 7.10. Which of the following interventions would you expect? (Select all that apply.) A. NS 1.5 L IV fluid bolus B. Insulin infusion at 5 units/hr C. Sodium bicarbonate 50 mmol IV push D. Vasopressin 10 units IM every 3 hr E. Potassium 20 mEq/L of IV fluid
ANS A, B, E A. NS 1.5 L IV fluid bolus B. Insulin infusion at 5 units/hr E. Potassium 20 mEq/L of IV fluid Dehydration is a common presenting issue in DKA, so the administration of fluids and insulin will help correct the hyperglycemia and acidosis. Sodium bicarbonate is not recommended unless the pH is less than 6.9. As dehydration is reversed, potassium moves back into the cells, and hypokalemia can result, so administration of replacement potassium is necessary.
8. A patient has a 10-year history of diabetes mellitus. The patient is admitted to the critical care unit with complaints of increased lethargy. Serum laboratory values validate the diagnosis of diabetic ketoacidosis (DKA). Which of the following symptoms is most suggestive of DKA? A. Irritability B. Excessive thirst C. Rapid weight gain D. Peripheral edema
ANS B Excessive thirst DKA has a predictable clinical presentation. It is usually preceded by patient complaints of malaise, headache, polyuria (excessive urination), polydipsia (excessive thirst), and polyphagia (excessive hunger). Nausea, vomiting, extreme fatigue, dehydration, and weight loss follow. Central nervous system depression, with changes in the level of consciousness, can lead quickly to coma.
24. The top priority in the initial treatment of diabetic ketoacidosis (DKA) is A. lowering the blood sugar. B. giving fluids. C. giving sodium bicarbonate to reverse the acidosis. D. determining the reason for the DKA.
ANS B giving fluids. A patient with DKA is dehydrated and may have lost 5% to 10% of body weight in fluids. A fluid deficit up to 6 L can exist in severe dehydration. Aggressive fluid replacement is provided to rehydrate both the intracellular and the extracellular compartments and prevent circulatory collapse.
11. The most common problem in the patient with type 2 diabetes is a(n) A. lack of insulin production. B. imbalance between insulin production and use. C. overproduction of glucose. D. increased uptake of glucose in the cells.
ANS B imbalance between insulin production and use. Type 2 diabetes results from a progressive insulin secretory defect in addition to insulin resistance.
29. A patient with diabetic ketoacidosis has an insulin drip infusing, and the nurse has just administered subcutaneous insulin. The nurse is alert for signs of hypoglycemia, which would include A. Kussmaul respirations and flushed skin. B. irritability and paresthesia. C. abdominal cramps and nausea. D. hypotension and itching.
ANS B irritability and paresthesia. Irritability and paresthesia are seen in hypoglycemia.
17. The major electrolyte disturbances that result from diuresis are A. low calcium and high phosphorus levels. B. low potassium and low sodium levels. C. high sodium and low phosphorus levels. D. low calcium and low potassium levels.
ANS B low potassium and low sodium levels. Serum sodium may be low as a result of the movement of water from the intracellular space into the extracellular (vascular) space. The serum potassium level is often normal; a low serum potassium level in diabetic ketoacidosis suggests that a significant potassium deficiency may be present.
27. When a patient in diabetic ketoacidosis (DKA) has insulin infusing intravenously, the nurse expects a drop in the serum levels of A. sodium and potassium. B. potassium and phosphate. C. bicarbonate and calcium. D. sodium and phosphate.
ANS B potassium and phosphate. Frequent verification of the serum potassium concentration is required for patients with DKA receiving fluid resuscitation and insulin therapy. The serum phosphate level is sometimes low (hypophosphatemia) in DKA. Insulin treatment may make this more obvious as phosphate is returned to the interior of the cell. If the serum phosphate level is less than 1 mg/dL, phosphate replacement is recommended.
32. An older patient presents with a serum glucose level of 900 mg/dL, hematocrit of 55%, and no serum ketones. Immediate attention must be given to A. clotting factors. B. rehydration. C. administration of insulin. D. sodium replacement.
ANS B rehydration The physical examination may reveal a profound fluid deficit. Signs of severe dehydration include longitudinal wrinkles in the tongue, decreased salivation, and decreased central venous pressure, with increases in heart rate and rapid respirations (Kussmaul air hunger does not occur). In older patients, assessment of clinical signs of dehydration is challenging.
2. The hallmark of hyperglycemic hyperosmolar syndrome (HHS) is A. hyperglycemia with low serum osmolality. B. severe hyperglycemia with minimal or absent ketosis. C. little or no ketosis in serum with rapidly escalating ketonuria. D. hyperglycemia and ketosis.
ANS B severe hyperglycemia with minimal or absent ketosis. The hallmarks of HHS are extremely high levels of plasma glucose with resulting elevations in serum hyperosmolality and osmotic diuresis. The disorder occurs mainly in patients with type II diabetes.
33. A patient with hyperglycemic hyperosmolar syndrome (HHS) has a serum glucose level of 400 mg/dL and a serum sodium level of 138 mEq/L. The intravenous fluid of choice would be A. D5W. B. 0.45% NS. C. 0.9% NS. D. D5/NS.
ANS C 0.9% NS. The fluid deficit may be as much as 150 mL/kg of body weight. The average 150-lb adult can lose more than 7 to 10 L of fluid. Physiologic saline solution (0.9%) is infused at 1 L/hr, especially for patients in hypovolemic shock if there is no cardiovascular contraindication. Several liters of volume replacement may be required to achieve a blood pressure and central venous pressure within normal range. Infusion volumes are adjusted according to the patient's hydration state and sodium level.
19. A patient in diabetic ketoacidosis has the following arterial blood gasses: pH 7.25; pCO2 30 mm Hg; HCO3- 16. The patient has rapid, regular respirations. The nurse's best response would be to A. ask the patient to breathe into a paper bag to retain CO2. B. administer sodium bicarbonate. C. administer insulin and fluids intravenously. D. prepare for intubation.
ANS C administer insulin and fluids intravenously. Replacement of fluid volume and insulin interrupts the ketotic cycle and reverses the metabolic acidosis. In the presence of insulin, glucose enters the cells, and the body ceases to convert fats into glucose.
18. The patient admitted in diabetic ketoacidosis has dry, cracked lips and is begging for something to drink. The nurse's best response would be to A. keep the patient NPO. B. allow the patient a cup of coffee. C. allow the patient water. D. allow the patient to drink anything he chooses.
ANS C allow the patient water. The thirst sensation is the body's attempt to correct the fluid deficit. Water is the best replacement.
25. The nurse knows that during the resuscitation of a patient with diabetic ketoacidosis, the IV line should be changed to a solution containing glucose when the A. patient becomes more alert. B. IV insulin has been infusing for 4 hours. C. blood glucose drops to 200 mg/dL. D. blood glucose drops to 100 mg/dL.
ANS C blood glucose drops to 200 mg/dL. When the serum glucose level decreases to 200 mg/dL, the infusing solution is changed to a 50/50 mix of hypotonic saline and 5% dextrose. Dextrose is added to replenish depleted cellular glucose as the circulating serum glucose level falls.
21. A patient in diabetic ketoacidosis is comatose with a temperature of 102.2° F. The nurse would suspect A. head injury. B. infarct of the hypothalamus. C. infection. D. heat stroke.
ANS C infection A patient in diabetic ketoacidosis can experience a variety of complications, including fluid volume overload, hypoglycemia, hypokalemia or hyperkalemia, hyponatremia, cerebral edema, and infection.
1. A patient with diabetes in the critical care unit is at risk for developing diabetic ketoacidosis (DKA) secondary to A. excess insulin administration. B. inadequate food intake. C. physiologic and psychologic stress. D. increased release of antidiuretic hormone (ADH).
ANS C physiologic and psychologic stress. Major neurologic and endocrine changes occur when an individual is confronted with physiologic stress caused by any critical illness, sepsis, trauma, major surgery, or underlying cardiovascular disease.
26. The nurse knows that the patient with DKA will need A. subcutaneous insulin. B. IV insulin. C. subcutaneous and IV insulin. D. combination 70%/30% insulin.
ANS C subcutaneous and IV insulin. The patient needs IV insulin for rapid onset but will also need subcutaneous insulin about 1 hour before the IV insulin is discontinued.
12. A patient weighs 140 kg and is 60 in. tall. The patient's blood sugar is being controlled by glipizide. As the nurse discusses discharge instructions, the primary treatment goal with this type 2 diabetes patient would be A. signs of hypoglycemia. B. proper injection technique. C. weight loss. D. increased caloric intake.
ANS C weight loss. This patient weighs 308 lb and is 5 feet tall. Diet management and exercise are interventions to facilitate weight loss in patients with type 2 diabetes.
14. A patient who has type 2 diabetes is on the unit after aneurysm repair. His serum glucose levels have been elevated for the past 2 days. He is concerned that he is becoming dependent on insulin. The best response for the nurse would be A. "This surgery may have damaged your pancreas. We will have to do more evaluation." B. "Perhaps your diabetes was more serious from the beginning." C. "You will need to discuss this with your physician." D. "The stress on your body has temporarily increased your blood sugar levels."
ANS D "The stress on your body has temporarily increased your blood sugar levels." Adrenal hormones released during stress elevate blood sugar by increasing insulin resistance and increasing hepatic gluconeogenesis.
13. A patient is admitted to the unit with extreme fatigue, vomiting, and headache. This patient has type 1 diabetes but has been on an insulin pump for 6 months. He states, "I know it could not be my diabetes because my pump gives me 24-hour control." The nurse's best response would be A. "You know a lot about your pump, and you are correct." B. "You're right. This is probably a virus." C. "We'll get an abdominal CT and see if your pancreas is inflamed." D. "We'll check your serum blood glucose and ketones."
ANS D "We'll check your serum blood glucose and ketones." Subcutaneous insulin pumps can malfunction. It is critical to assess glucose and ketone levels to evaluate for diabetic ketoacidosis.
9. A patient has a 10-year history of diabetes mellitus. The patient is admitted to the critical care unit with complaints of increased lethargy. Serum laboratory values validate the diagnosis of diabetic ketoacidosis.Which of the following statements best describes the rationale for administrating potassium supplements with the patient's insulin therapy? A. Potassium replaces losses incurred with diuresis. B. The patient has been in a long-term malnourished state. C. IV potassium renders the infused solution isotonic. D. Insulin drives the potassium back into the cells.
ANS D Insulin drives the potassium back into the cells. Low serum potassium (hypokalemia) occurs as insulin promotes the return of potassium into the cell and metabolic acidosis is reversed. Replacement of potassium by administration of potassium chloride (KCl) begins as soon as the serum potassium falls below normal. Frequent verification of the serum potassium concentration is required for patients with DKA who are receiving fluid resuscitation and insulin therapy.
20. A patient in diabetic ketoacidosis is very lethargic and has a "funny" odor to his breath. The nurse would suspect this to be a result of A. alcohol intoxication. B. hyperglycemia. C. hyperphosphatemia. D. acetone.
ANS D acetone Acid ketones dissociate and yield hydrogen ions (H) that accumulate and precipitate a fall in serum pH. The level of serum bicarbonate also decreases consistent with a diagnosis of metabolic acidosis. Breathing becomes deep and rapid (Kussmaul respirations) to release carbonic acid in the form of carbon dioxide. Acetone is exhaled, giving the breath its characteristic "fruity" odor.
30. A patient was admitted with diabetic ketoacidosis 1 hour ago and is on an insulin drip. Suddenly, the nurse notices frequent premature ventricular contractions (PVCs) on the electrocardiogram. The expected intervention would be to A. administer a lidocaine bolus. B. administer a lidocaine drip. C. synchronize cardioversion. D. evaluate electrolytes.
ANS D evaluate electrolytes. Hyperkalemia occurs with acidosis or with overaggressive administration of potassium replacement in patients with renal insufficiency. Severe hyperkalemia is demonstrated on the cardiac monitor by a large, peaked T wave; flattened P wave; and widened QRS complex.
31. A patient with type 2 diabetes is admitted. He is very lethargic and hypotensive. A diagnosis of hyperglycemic hyperosmolar syndrome (HHS) is made based on laboratory values of A. decreased serum glucose and increased serum ketones. B. increased urine ketones and decreased serum osmolality. C. increased serum osmolality and increased serum potassium. D. increased serum osmolality and increased serum glucose.
ANS D increased serum osmolality and increased serum glucose. Laboratory findings are used to establish the definitive diagnosis of HHS. Plasma glucose levels are strikingly elevated (greater than 600 mg/dL). Serum osmolality is greater than 320 mOsm/kg.
The patient with type 1 diabetes arrives in the emergency department with a glucose level of 390 mg/dL and positive result for ketones. Vital signs are 110/70 mm Hg, 120 beats/minute, and 28 deep, sighing respirations/minute. What is the priority need for the patient? A. Oxygen B. Intravenous (IV) fluids C. Albuterol (Ventolin) D. Metformin (Glucophage)
B. Intravenous (IV) fluids A patient in diabetic ketoacidosis (DKA) needs IV fluids and insulin to stop the tissue breakdown resulting in ketone bodies and acidosis. The initial goal is fluid and electrolyte balance. Kussmaul respirations indicate the body is attempting to compensate by blowing off the carbon dioxide, but it is ineffective as long as the body continues to break down the ketone bodies and remains in metabolic acidosis.
You are beginning to teach a diabetic patient about the vascular complications of diabetes. Which information is appropriate for you to include? A. Macroangiopathy does not occur in type 1 diabetes but does affect type 2 diabetics who have severe disease. B. Microangiopathy is specific to diabetes and most commonly affects the capillary membranes of the eyes, kidneys, and skin. C. Renal damage resulting from changes in large and medium-sized blood vessels can be prevented by careful glucose control. D. Macroangiopathy causes slowed gastric emptying and the sexual impotency experienced by most patients with diabetes.
B. Microangiopathy is specific to diabetes and most commonly affects the capillary membranes of the eyes, kidneys, and skin. Microangiopathy occurs in type 1 and type 2 diabetes mellitus. When it affects the eyes, it is called diabetic retinopathy. When kidneys are affected, the patient has nephropathy. When the skin is affected, it can lead to diabetic foot ulcers. Sexual impotency and slowed gastric emptying result from microangiopathy.
The serum potassium level of a client who has diabetic ketoacidosis is 5.4 mEq/L (5.4 mmol/L). What would the nurse expect to see on the ECG tracing monitor? A. Abnormal P waves and depressed T waves B. Peaked T waves and widened QRS complexes C. Abnormal Q waves and prolonged ST segments D. Peaked P waves and an increased number of T waves
B. Peaked T waves and widened QRS complexes Potassium is the principal intracellular cation, and during ketoacidosis it moves out of cells into the extracellular compartment to replace potassium lost as a result of glucose-induced osmotic diuresis; overstimulation of the cardiac muscle results. The T wave is depressed in hypokalemia. Initially, the QT segment is short, and as the potassium level rises, the QRS complex widens. P waves are abnormal because the PR interval may be prolonged and the P wave may be lost; however, the T wave is peaked, not depressed. The ST segment becomes depressed. The PR interval is prolonged, and the P wave may be lost. QRS complexes and thus T waves become irregular, and the rate does not necessarily change.
Which elevated laboratory finding is the best indication of potential diabetic nephropathy? A. Blood urea nitrogen (BUN) level B. Urine albumin-to-creatinine ratio C. Urine specific gravity D. Chloride (Cl-) level
B. Urine albumin-to-creatinine ratio Screening for nephropathy depends on the urinary albumin-to-creatinine ratio and a serum creatinine level. BUN alone, without correction to creatinine, can indicate many other issues, including dehydration and liver function. Unless there is renal failure, urine specific gravity is more indicative of dehydration.
Which symptoms reported by a patient with diabetes mellitus are most important to follow-up? A. "My vision has been getting fuzzier over the past year." B. "I cannot read the small print anymore." C. "There is something like a veil of blackness coming across my vision." D. "I have yellow discharge from one eye."
C. "There is something like a veil of blackness coming across my vision." Diabetic retinopathy, particularly proliferative retinopathy, can cause retinal detachment, which has the classic new symptom of a veil coming across the field of vision. This requires emergency treatment. Chronic blurry vision can be cataracts and is not emergent. Change in the ability to read things near to the eye (presbyopia or farsightedness) is an age-related change and not emergent. Conjunctivitis needs treatment but is not as emergent as retinal detachment.
The patient has type 1 diabetes mellitus and is found unresponsive with cool and clammy skin. What action is a priority? A. Obtain a serum glucose level. B. Give hard candy under the tongue. C. Administer glucagon per standing order. D. Notify the health care provider.
C. Administer glucagon per standing order. The patient has signs and symptoms of hypoglycemia for which treatment should be the priority. Glucagon stimulates a strong hepatic response to convert glycogen to glucose and therefore makes glucose rapidly available. Waiting for a serum result (up to an hour) is improper because brain cells continue to die from a lack of glucose. Nothing solid should be placed in the mouth when the patient has an altered level of consciousness and can aspirate. With obvious symptoms, emergent treatment takes priority over notifying the health care provider.
The patient had a hypoglycemic episode and is treated with a concentrated glucose oral tablet. Fifteen minutes later the capillary glucose level (Accu-Check) is 150 mg/dL. What action should you take? A. Administer a second bolus of glucose solution. B. Administer regular insulin per sliding scale. C. Have the patient eat peanut butter and toast. D. Obtain a serum glucose level.
C. Have the patient eat peanut butter and toast. The patient has had an appropriate response to the glucose. Now a complex carbohydrate is needed to prevent hypoglycemia from reoccurring. There is no need for a second bolus of glucose because the result is within normal range. Insulin is not given, even though the glucose level is slightly elevated. The short-acting glucose is metabolized and insulin administration can increase the risk of a second hypoglycemic reaction. A serum confirmation of the level can be obtained but is not the priority.
The patient in the emergency department is diagnosed with diabetic ketoacidosis. Which laboratory value is essential for you to monitor? A. Magnesium (Mg) B. Hemoglobin (Hb) C. White blood cells (WBCs) D. Potassium (K)
D. Potassium (K) Even if the patient has normal potassium levels, there can be significant hypokalemia when insulin is administered as it pushes the serum potassium intracellularly. This can lead to life-threatening hypokalemia. The other options are not as significant.
What is the best teaching for a patient who is newly diagnosed with diabetes mellitus type 2? A. Read a Snellen chart yearly. B. Be checked out for presbycusis. C. Notify the doctor if your vision has color distortion. D. See an ophthalmologist for a dilated eye examination yearly.
D. See an ophthalmologist for a dilated eye examination yearly. The earliest and most treatable stages of diabetic retinopathy often produce no changes in the vision. Because of this, the patient with type 2 diabetes should have a dilated eye examination by an ophthalmologist at the time of diagnosis and annually thereafter for early detection and treatment.
What is most helpful in the prevention of nephropathy in a patient with diabetes mellitus? A. Acid-ash diet B. Ensuring adequate fluid intake for renal perfusion C. Preventing obstruction from benign prostatic hyperplasia (BPH) D. Stopping smoking
D. Stopping smoking Risk factors for diabetic nephropathy include hypertension, genetic predisposition, smoking, and chronic hyperglycemia. Diabetic nephropathy is an intrarenal microvascular complication in which the glomeruli of the kidney are damaged. The kidney receives about 25% of the cardiac output, and inadequate fluids or shock resulting in adequate perfusion is a prerenal cause. BPH is a postrenal cause of kidney pathology.
What is the glucose levels of Diabetic Ketoacidosis (DKA).....
Glucose Levels > 300mg/dL
At what Potassium should be stated in order to continue or give an Insulin Bolus
Greater than 3.3mE1/L
If the Potassium levels are NOT falling after giving the patient Insulin with DKA, the treatment would be considered adequate or inadequate
Inadequate
A patient with Diabetic Ketoacidosis (DKA) would have an increased or decreased Aion Gap
Increase (normal range: 12-15mEq/L)
Which Diabetic Population usually present with Diabetic Ketoacidosis (DKA)
Type I
Can Type II Diabetic Patients present with Diabetic Ketoacidosis (DKA) if under exterme stress
Yes
What is the rationale for administration of potassium supplement when a patient is on insulin therapy
Insulin drives Potassium back into the cell
What type of respirations would present for a patient with Diabetic Ketoacidosis (DKA).....
Kussmaul Respirations
What Diabetic Ketoacidosis complication is a result of ketones exerting in a strong osmotic effect with volume and electrolyte depletion (e.g. urinary ketones also promote excretion of positvely charged ions)
Osmotic Diuresis
A diabetic patient has a serum glucose level of 824 mg/dL (45.7 mmol/L) and is unresponsive. After assessment of the patient, you suspect DKA rather than HHS based on the finding of A. polyuria. B. severe dehydration. C. rapid, deep respirations. D. decreased serum potassium.
C. rapid, deep respirations. Rapid, deep respirations are Kussmaul's and are are the body's attempt to reverse metabolic acidosis through exhalation of excess carbon dioxide. Symptoms of DKA include manifestations of dehydration, such as poor skin turgor, dry mucous membranes, tachycardia, and orthostatic hypotension. Kussmaul respirations (rapid, deep breathing associated with dyspnea) are the body's attempt to reverse metabolic acidosis through exhalation of excess carbon dioxide. Acetone is detected on the breath as a sweet, fruity odor.
What is the recommended glucose level of start Dextrose in order to prevent hypoglycemia
250mg/dL
What is the main breath smell for Diabetic Ketoacidosis (DKA).....
Fruity Breath
If a patient has an ABG of pH: 7.16 PCO2: 27 PO2: 106 Sat: 96%; Anion Gap of 20 & BG: 496mg/dL
Diabetic Ketoacidosis (DKA) & Metabolic Acidosis
The patient presents to the emergency department with a glucose level of 400 mg/dL, ketone result of 2+, and rapid respirations with a fruity odor. What finding do you anticipate? A. pH below 7.30 B. Urine specific gravity below 1.005 C. High sodium bicarbonate levels D. Low blood urea nitrogen (BUN) level
A. pH below 7.30 The patient is in metabolic acidosis, which is a pH below 7.35. Dehydration results in a high urine specific gravity (at the upper end of the normal range, or above 1.025 to 1.030). Sodium bicarbonate levels are low in metabolic acidosis. The dehydration that occurs with DKA elevates the BUN level.
If the Potassium levels are falling after giving the patient Insulin with DKA, the treatment would be considered adequate or inadequate
Adequate
The patient has diabetes mellitus and macroalbuminuria. The patient asks you why the physician is prescribing the angiotensin-converting enzyme (ACE) inhibitor lisinopril (Zestril) for him even though his blood pressure is well-controlled. What is your response? A. It helps prevent hypertension as diabetics are prone to it. B. ACE inhibitors delay the progression of nephropathy in patients with diabetes. C. ACE inhibitors prevent macrovascular complications. D. ACE inhibitors help prevent atherosclerosis.
B. ACE inhibitors delay the progression of nephropathy in patients with diabetes. ACE inhibitors and angiotensin II receptor antagonists (ARBs) are used to treat hypertension and delay the progression of nephropathy in patients with diabetes. ACE inhibitors are not used prophylactically. ACE inhibitors do not affect macrovascular complications. Nephropathy is a microvascular complication.
The patient is managed with NPH and regular insulin injections before breakfast and before dinner. When is the patient most likely to have a hypoglycemic reaction? A. After breakfast B. Before lunch C. During lunch D. After lunch
B. Before lunch The regular insulin peak occurs about 2 to 3 hours with a duration of 5 to 6 hours. If too much insulin or not enough food is given, the most likely time of hypoglycemia is before lunch, when the regular insulin is still present, the NPH has its onset, and the breakfast food has been metabolized.
Which lower extremity or foot finding is a sign of sensory neuropathy in a patient with diabetes mellitus? A. Dusky when legs are dependent B. Pitting pedal edema C. Intermittent claudication D. Strong pedal pulse
C. Intermittent claudication Peripheral arterial disease (PAD) is caused by a reduction of blood flow to the lower extremities. Classic signs include intermittent claudication, pain at rest, cold feet, loss of hair, delayed capillary filling, and dependent rubor. Dusky legs when they are dependent, pitting pedal edema, and a strong pedal pulse are signs of peripheral venous disease.
If a patient with a history of Type I Diabetes presents with the signs/syptoms of rapid onset, glucose level of 340mg/dL, POLYURIA, POLYDISPIA, weight loss, voimting, abdominal pain, EXCESSIVE DEHYDRATION, dry skin, drink muscus membrane, tachycardia, weakness, FRUITY BREATH, neurological deficit & KUSSMAUL RESPIRATIONS, the nurse would expect which condition.......
Diabetic Ketoacidosis (DKA)
What is a finding in DKA that is not seen in hyperosmolar hyperglycemic syndrome (HHS)? A. Glucose level above 400 mg/dL B. Hyperkalemia C. Ketones in blood D. Urine output of 30 mL/hr
C. Ketones in blood The main difference between the two conditions is that ketone bodies are absent or minimal in HHS because the body has enough insulin to prevent ketoacidosis. Both have high glucose levels, although the level in HHS tends to be higher (above 600 mg/dL). Hypokalemia is possible in both, although it is more likely and serious in DKA. Urine output of 30 mL/hr is normal obligatory output; both conditions are likely to have dehydration and decreased output.
A client is diagnosed with diabetic ketoacidosis. Which insulin should the nurse expect the health care provider to prescribe? A. NPH insulin B. Inhaled insulin C. Regular insulin D. Insulin glargine
C. Regular insulin
Which assessment is the most sensitive indicator that the IV fluid administration may be too rapid when treating a patient with DKA and a history of renal disease? A. Pedal edema B. Tachypnea C. Urine output of 40 mL/hour D. Change in the level of consciousness
D. Change in the level of consciousness Too rapid fluid replacement can lead to hyponatremia and cerebral edema. Pedal edema is a later and relatively insignificant sign. In a bedridden patient, edema is more evident in the sacral area. The Kussmaul respirations are expected; crackles auscultated in the lungs are a more sensitive indicator. The desired urine output for adequate hydration is 30 to 60 mL/hr.
Which condition is a result of insulin deficiency and glucagon excess leads to the promotion of lipolysis, increase FFA delivery to the liver where they are converted to free fatty Acyl CoA ketones
Diabetic Ketoacidosis
Diabetic Ketoacidosis (DKA) Nursing Interventions: 1. Aggressive Hydration (e.g. Fluids)-->2. Insulin Infusion to correct gluocse & acidosis (e.g. bolus)-->3. Glucose < 300mg/dL, begin dextrose-->4. Urine output, start potassium-->5. correct electrolytes abnormailites-->6. protect airway if altered mental status
Diabetic Ketoacidosis (DKA) Nursing Interventions: 1. Aggressive Hydration (e.g. Fluids)-->2. Insulin Infusion to correct gluocse & acidosis (e.g. bolus)-->3. Glucose < 300mg/dL, begin dextrose-->4. Urine output, start potassium-->5. correct electrolytes abnormailites-->6. protect airway if altered mental status
A patient with Diabetic Ketoacidosis (DKA) would have.......dehydration
Excessive
What type of urine would the patient have with Diabetic Ketoacidosis (DKA)
Postive Urine Ketones
Why give the patient Dextrose after an Insulin Bolus
Prevent Hypoglycemia
The onset of Diabetic Ketoacidosis (DKA) is.....
Rapid
