Prep U's - Chapter 41 - Drug Therapy for Diabetes Mellitus

The nurse assesses a client's blood glucose level after administering insulin. Which result would the nurse interpret as indicative of severe hypoglycemia? A. 34 mg/dL B. 72 mg/dL C. 65 mg/dL D. 48 mg/dL

Answer: A Rationale: Blood glucose levels below 40 mg/dL are indicative of severe hypoglycemia.

A nurse is presenting an educational event at a local senior citizens' club about diabetes. What would the nurse tell the attendees at the event about diabetes? A. It is a complicated disorder that alters the metabolism of glucose. B. It always starts in childhood. C. It can cause bruising of the tissue all the way to the bone. D. It sometimes causes widespread changes in the blood vessels.

Answer: A Rationale: Diabetes is a complicated disorder that alters the metabolism of glucose, fats, and proteins affecting many end organs and causing numerous clinical complications. It is part of the metabolic syndrome, a collection of conditions that predispose to cardiovascular disease.

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? A. the past 1 or 2 months. B. the past 12 to 24 hours. C. the past 7 to 10 days. D. the past 3 or 4 months.

Answer: D Rationale: 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.

After teaching an in-service presentation to a group of nurses about diabetes and insulin, the presenter determines that the session was successful when the group correctly chooses which insulins as rapid-acting? Select all that apply. A. Insulin detemir B. Isophane insulin suspension C. Insulin glulisine D. Insulin glargine E. Insulin aspart

Answer: C, E Rationale: Insulin aspart and insulin glulisine are rapid-acting insulins. Isophane insulin suspension is an intermediate-acting insulin. Insulin glargine and detemir are long-acting insulins.

Which would a nurse identify as an example of a sulfonylurea? A. Metformin B. Acarbose C. Miglitol D. Glyburide

Answer: D Rationale: Glyburide is an example of a sulfonylurea. Metformin is classified as a biguanide. Acarbose and miglitol are alpha-glucosidase inhibitors.

A nurse is preparing an in-service presentation for a group of staff members on diabetes. Which would the nurse include as the primary delivery system for insulin? A. External pump B. Subcutaneous injection C. Jet injector D. Insulin pen

Answer: B Rationale: Although other delivery systems are available for insulin administration such as the jet injector, insulin pen, and external pump, subcutaneous injection remains the primary delivery system.

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? A. Risk for Fluid Volume Deficit B. Anxiety C. Altered Breathing Pattern D. Acute confusion

Answer: C Rationale: 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. There are no problems with fluid balance. Acute Confusion would be appropriate if the client was experiencing hypoglycemia. Anxiety would be appropriate for a client who is newly diagnosed with diabetes and having difficulty accepting the diagnosis.

A client is prescribed sitagliptin. The nurse would expect to administer this drug by which route? A. Subcutaneous B. Intramuscular C. Intravenous D. Oral

Answer: D Rationale: Sitagliptin is administered orally.

A client who began treatment for type 2 diabetes 8 months ago is now meeting with a diabetic nurse for a scheduled follow-up. How can the nurse best assess the client's glycemic control since beginning treatment? A. Assess the most recent hemoglobin A1C levels. B. Review and discuss the data contained in the client's written blood glucose log. C. Arrange to have the client's random blood glucose measured. D. Dialogue with the client about implemented management strategies.

Answer: A Rationale: Health care providers look at the glycosylated hemoglobin (hemoglobin A1C) levels to assess the effectiveness of treatment. Because glucose stays attached to hemoglobin for the life of the red blood cell, which is about 120 days, the hemoglobin A1C level reflects the average blood glucose level over the past 3 months. Reviewing blood glucose readings, measuring the client's random blood glucose, and dialoguing with the client are all therapeutic strategies, but hemoglobin A1C is most accurate.

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? A. "Insulin assists glucose molecules to enter the cells of muscle and fat tissues." B. "Insulin causes fat to be broken down to provide energy for the body." C. "Insulin is used to move carbohydrate particles from the gastrointestinal system to the liver." D. "Insulin is stimulated by the liver to break down proteins and provide the body with nutrients."

Answer: A Rationale: 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 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? A. "The different onsets and peaks of the two types provide better overall glucose control." B. "The combination negates the risk of adverse effects that would likely accompany a single, larger dose." C. "NPH stimulate the pancreas to produce more insulin, while regular insulin provides your body's short-term needs." D. "NPH prevents regular insulin from being broken down in the body, allowing the use of a lower dose."

Answer: A Rationale: Regular insulin will begin working within 30 to 60 minutes and peak within 2 to 4 hours and a 6- to 12-hour duration of action, whereas NPH insulin has an onset of 60 to 90 minutes and peaks in 4 to 12 hours, with a 24-hour duration of action. By giving both drugs at once, the client gets rapid blood glucose control within 30 minutes from the regular insulin, and the control lasts 24 hours due to NPH's long duration of action. NPH has no effect on the breakdown of regular insulin, and there is not necessarily a reduced risk of adverse effects. NPH does not stimulate the pancreas toward increased insulin production.

A nurse is preparing to administer insulin to the client. Which interventions should the nurse perform before administering each insulin dose? A. Inspect the previous injection site for inflammation. B. Mix the insulin with sterile water in the syringe. C. Check for symptoms of myalgia or malaise. D. Keep prefilled syringes horizontally.

Answer: A Rationale: 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 not be mixed with other drugs in the syringe. Some types of insulin may be combined in one syringe, but sterile water is never used.

A nurse must recognize the duration of insulin as to not cause harm to the client with administration of the improper type of insulin. Which insulins are long-acting insulin? (Select all that apply.) A. Insulin detemir (Levemir) B. Insulin glargine (Lantus) C. Insulin glulisine (Apidra) D. Insulin apart (NovoLog) E. Insulin lispro (Humalog)

Answer: A, B Rationale: Insulin glargine (Lantus) and insulin detemir (Levemir) are long-acting insulins with a duration of 24 hours.

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? Select all that apply. A. Hard candy B. Glucose tablets C. Insulin detemir D. Orange or other fruit juice E. Insulin glargine

Answer: A, B, D Rationale: 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.

The nurse is assessing a client for risk factors associated with type 2 diabetes. Which findings would the nurse prioritize? Select all that apply. A. History of gestational diabetes. B. Younger age. C. Obesity. D. Impaired glucose tolerance. E. Caucasian race.

Answer: A, C, D Rationale: 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 (African Americans, Hispanic/Latino Americans, Native Americans, and some Asian Americans).

A nurse should take what steps prior to administering insulin glargine (Lantus) to a client? Select all that apply. A. Check the health care provider's orders for the type and dosage of insulin. B. Mix with short-acting insulin prior to administration. C. Remove all air bubbles from the syringe barrel. D. Shake the vial vigorously. E. Check the expiration date on the vial.

Answer: A, C, E Rationale: 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.

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: A. hypoglycemia. B. hyperglycemia. C. hyperkalemia. D. hypokalemia.

Answer: B Rationale: 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 student asks the nursing instructor what insulin gives the quickest therapeutic effect has once administered. What would be the best response? A. Ultralente (Humulin U Ultralente) B. Regular (Humulin R) C. NPH (Humulin N) D. PZI (Humulin U)

Answer: B Rationale: Regular insulin has the quickest onset of 30-60 minutes. PZI and ultralente have an onset of 4-8 hours. NPH has an onset of 60-90 minutes.

Which HbA1c result would indicate that a client's diabetes is under good control? A. 14% B. 7% C. 8% D. 10%

Answer: B Rationale: 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 educating a newly diagnosed diabetic who must learn how to give himself insulin injections. The nurse tells the client that insulin is absorbed fastest from which area of injection? A. Deltoid B. Abdomen C. Hip D. Thigh

Answer: B Rationale: Studies indicate that insulin is absorbed fastest from the abdomen, followed by the deltoid, thigh, and hip.

A nurse is assigned to administer glargine to a patient at a health care facility. What precaution should the nurse take when administering glargine? A. Shake the vial vigorously before withdrawing insulin. B. Avoid mixing glargine with another insulin. C. Administer glargine via IV route. D. Administer insulin that has been refrigerated.

Answer: B Rationale: When administering glargine to the patient, the nurse should avoid mixing it with other insulin 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 SC 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 it is to be stored for about three months for later use.

A nurse has administered glimepiride to a client with diabetes. Which findings on the ongoing assessment should the nurse prioritize? Select all that apply. A. Lactic acidosis B. Hypoglycemia C. Heartburn D. Nausea E. Edema

Answer: B, C, D Rationale: Adverse reactions associated with sulfonylureas, like glimepiride, include hypoglycemia, anorexia, nausea, vomiting, epigastric discomfort, weight gain, heartburn, and various vague neurologic symptoms, such as numbness and weakness of the extremities. Lactic acidosis is a risk when clients are using metformin and have impaired kidneys. Thiazolidinediones should be used cautiously in clients with edema.

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? A. U-50 (50 units/mL) insulin B. U-30 (30 units/mL) insulin C. U-10 (10 units/mL) insulin D. U-20 (20 units/mL) insulin

Answer: C Rationale: 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 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? A. The insulin is more effective in establishing control of blood glucose levels initially. B. More insulin is needed than that which the client can produce naturally. C. Insulin is needed because the beta cells of the pancreas are no longer functioning. D. The client most likely does not exercise enough to control his glucose levels.

Answer: C Rationale: 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? A. Hypoglycemia is a possible side effect of the medication. B. Do not drink alcohol while taking this medication. C. The medication should have a fixed dose which cannot be manipulated. D. Contact your primary care provider before starting a new over-the-counter medication.

Answer: C Rationale: 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.

The home care nurse is caring for an older adult client who has been diagnosed with type 1 diabetes. The client has visual impairment and cannot read the numbers on the syringe when preparing insulin for administration nor afford the cost of prefilled auto syringes. What strategy might the nurse use to help this client comply with insulin needs between visits? A. Change the client to oral antidiabetics. B. Ask a neighbor to come over every day to prepare the medication. C. Prepare a week's supply of syringes and refrigerate. D. Have the client use a magnifying glass.

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

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? A. acarbose B. glyburide C. regular insulin D. NPH insulin

Answer: C Rationale: Only regular insulin can be administered IV. No other insulins or oral antidiabetic medications can be given IV.

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? A. creatinine B. platelet count C. liver enzymes D. d-dimer

Answer: C Rationale: 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. Platelets, d-dimer, and tests of renal function are less significant to the safety and efficacy of treatment.

A nurse is conducting a teaching session for a client newly diagnosed with type 2 diabetes on the importance of monitoring the blood glucose. The nurse determines additional teaching is necessary after the client makes which statement? A. "I should massage my finger to get a hanging drop of blood." B. "I should avoid smearing the blood on the test strip." C. "I should prick the tip of my finger to get the blood." D. "I should clean my finger with warm, soapy water."

Answer: C Rationale: The client should insert the lancet to prick the side of the finger, not the tip, because the side has more capillaries and fewer nerve endings. The finger should be washed with warm, soapy water and then dried before testing. The client should massage the finger to get a hanging drop of blood to be placed on the test strip. The client needs to avoid smearing the blood on the strip to prevent inaccurate readings.

A nurse is working with a newly diagnosed diabetic client on understanding hypoglycemia and insulin reactions. Which action would be most important for the client to understand when planning the response to an insulin reaction? A. Notify your health care provider immediately. B. Inject a prescribed dose of insulin as soon as you suspect the reaction is occurring. C. Take an oral dose of some form of glucose as soon as possible. D. Stay calm and still until the reaction subsides.

Answer: C Rationale: The initial action of the client should be to take some form of oral glucose. It would also be appropriate to call the provider, but this will delay self-treatment and should be done after the administration of the glucose. Injecting insulin would cause further harm to the client and is not an option. It is good to stay calm, but the reaction will not subside without intervention.

A nurse is caring for a patient who has developed a hypoglycemic reaction. Which intervention should the nurse perform if swallowing and gag reflexes are present in the patient? A. Administer the insulin via insulin pump. B. Administer glucagon by the parenteral route. C. Give oral fluids or candy. D. Administer oral antidiabetics to the patient.

Answer: C Rationale: The nurse should administer oral fluids or candy to the hypoglycemic patient with swallowing and gag reflexes. If the patient is unconscious the nurse should administer glucose or glucagon parenterally. The nurse should administer insulin through an insulin pump to special categories of diabetic patients, such as pregnant women with diabetes and renal transplantation. Oral antidiabetic drugs are administered to patients with type 2 diabetes.

A client with hyperinsulinism has been prescribed diazoxide. After administration, which adverse reaction should the nurse prioritize? A. Flatulence B. Epigastric discomfort C. Tachycardia D. Myalgia

Answer: C Rationale: 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. Myalgia, fatigue, and headache are the adverse reactions observed in clients undergoing pioglitazone HCl drug therapy. Flatulence is one of the adverse reactions found in clients receiving metformin drug therapy. Epigastric discomfort is one of the adverse reactions observed in clients receiving acetohexamide drugs.

A client with hyperinsulinism has been prescribed diazoxide. After administration, which adverse reaction should the nurse prioritize? A. Myalgia B. Flatulence C. Tachycardia D. Epigastric discomfort

Answer: C Rationale: 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. Myalgia, fatigue, and headache are the adverse reactions observed in clients undergoing pioglitazone HCl drug therapy. Flatulence is one of the adverse reactions found in clients receiving metformin drug therapy. Epigastric discomfort is one of the adverse reactions observed in clients receiving acetohexamide drugs.

A nurse is preparing a teaching plan for a patient who is prescribed a meglitinide. What instruction should the nurse include in the teaching plan for the patient? A. Use commercial weight-loss products with the drug. B. Take the drug one hour before the meal. C. Avoid drug administration in the case of a skipped meal. D. Report respiratory distress or muscular aches.

Answer: C Rationale: The nurse's teaching plan for the patient should instruct the patient taking meglitinides to avoid drug administration in the case of a skipped meal. The nurse should instruct the patient to take the meal within 15 to 30 minutes of administering the drug. The nurse should instruct the patient to report to the PHCP any instances of respiratory distress or muscular aches when administering metformin. The nurse should instruct the patient to avoid commercial weight-loss products, alcohol, dieting, and strenuous exercise programs unless approved by the PHCP.

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 (18 mmol/L). What rationale does the nurse provide explaining this elevated blood glucose level? A. The client's accident was caused by undiagnosed hyperglycemia. B. The client may have sustained pancreatic trauma. C. The client's stress reaction likely caused an increase in blood sugar. D. The client most likely ate a meal just before the accident.

Answer: C Rationale: The stress reaction elevates the blood glucose concentration above the normal range. In severe stress situations, the blood glucose level can be very high (300 to 400 mg/dL). The body uses that energy to fight the insult or flee from the stressor. It would be unlikely for a hyperglycemic episode to cause a change in consciousness that would result in an accident. Eating food does not cause such a large increase in glucose levels. Pancreatic trauma does not normally cause a precipitous increase in blood glucose levels.

When describing the effects of incretins on blood glucose control to a group of students, which would an instructor include? A. Increases protein building. B. Increases glucagon release. C. Increases GI emptying. D. Increases insulin release.

Answer: D Rationale: Incretins increase insulin release, decrease glucagon release, slow GI emptying, and stimulate the satiety center. Growth hormone increases protein building.

A client's current condition requires rapid reduction of blood sugar levels. Which type of insulin will have the most rapid onset of action? A. isophane (NPH) B. isophane (NPH) C. Humulin R D. insulin lispro

Answer: D Rationale: 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.

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: A. increasing the use of insulin by the muscles. B. preventing glucose absorption from the stomach. C. stopping the production of insulin in the liver. D. increasing insulin secretion from the pancreas.

Answer: D Rationale: The hypoglycemic action of glyburide results from the stimulation of pancreatic beta cells, leading to increased insulin secretion.

The nurse is interviewing a client who was diagnosed with type 2 diabetes four months ago. The client does not record glucometer readings. What laboratory test does the nurse anticipate the health care provider will order for this client? A. Stat urine for glucose. B. Fasting blood glucose in the AM. C. Insulin level. D. HbA1c

Answer: D Rationale: The nurse anticipates that the glycosylated hemoglobin (HbA1c) will be ordered for this client because it provides an average of the client's blood glucose level for the last three- to four-month period. It will also tell how well controlled the client's blood glucose is. A stat urine for glucose and an FBG in the AM will only indicate the client's current blood glucose level, not how well it is being controlled. An insulin level will not give the information needed to understand the client's control of blood glucose.