Chapter 13: Diabetes mellitus

25. You are caring for a diabetic patient admitted with hypoglycemia that occurred at home. Which teaching points for treatment of hypoglycemia at home would you include in a teaching plan for the patient and family before discharge? (Select all that apply.) 1. Signs and symptoms of hypoglycemia include hunger, irritability , weakness, headache, and blood glucose less than 60 mg/dL. 2. Treat hypoglycemia with 4 to 8 g of carbohydrate such as glucose tablets or 1⁄4 cup of fruit juice. 3. Retest blood glucose in 30 minutes. 4. Repeat the carbohydrate treatment if the symptoms do not resolve. 5. Eat a small snack of carbohydrate and protein if the next meal is more than an hour away .

25. Ans: 1, 4, 5 The manifestations listed in option 1 are correct. The symptoms should be treated with carbohydrate, but 10 to 15 g (not 4 to 8 g). Glucose should be retested at 15 minutes; 30 minutes is too long to wait. Options 4 and 5 are correct. Focus: Prioritization

6. A 58-year-old with type 2 diabetes was admitted to your unit with a diagnosis of chronic obstructive pulmonary disease (COPD) exacerbation. When you prepare a care plan for this patient, what would you be sure to include? (Select all that apply.) 1. Fingerstick blood glucose checks before meals and at bedtime 2. Sliding-scale insulin dosing as ordered

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 * Ans: 1, 2, 5 When a diabetic patient is ill, glucose levels become elevated, and administration of insulin may be necessary . Teaching or reviewing the components of proper foot care is always a good idea with a diabetic patient. Bed rest is not necessary , and glucose level 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 diabetic patients. Focus: Prioritization

8. An LPN/LVN is to administer rapid-acting insulin (Lispro) to a patient with type 1 diabetes. What essential information would you be sure to tell the LPN/LVN? 1. Give this insulin after the patient's food tray has been delivered and the patient is ready to eat. 2. Only give this insulin if the patient's fingerstick glucose reading is above 200 mg/dL. 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 .

8. Ans: 1 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. Long-acting insulins mimic the action of the pancreas. Regular insulin is the only insulin that can be given IV . Focus: Assignment, supervision

5. The plan of care for a diabetic patient includes all of these interventions. Which intervention should you delegate to a UAP? 1. Checking to make sure that the patient's bath water is not too hot 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

Ans: 1 Checking the bath water temperature is part of assisting with activities of daily living and is within the education and scope of practice of the UAP . Discussing community resources, teaching, and assessing require a higher level of education and are appropriate to the scope of practice of licensed nurses. Focus: Delegation

11. You are caring for a diabetic patient who is developing diabetic ketoacidosis (DKA). Which task delegation is most appropriate? 1. Ask the unit clerk to page the physician to come to the unit. 2. Ask the LPN/LVN to administer IV push insulin according to a sliding scale. 3. Ask the UAP to hang a new bag of normal saline. 4. Ask the UAP to get the patient a cup of orange juice.

Ans: 1 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. 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. Focus: Delegation, supervision

23. You are orienting a new graduate nurse who is providing diabetes education for a patient about insulin injection. For which teaching statement by the new nurse must you intervene? 1. "To prevent lipohypertrophy , be sure to rotate injection sites from the abdomen to the thighs." 2. "To correctly inject the insulin, lightly grasp a fold of skin and inject at a 90-degree angle." 3. "Always draw your regular insulin into the syringe first before your NPH insulin." 4. "Avoid injecting the insulin into scarred sites because those areas slow the absorption rate of insulin."

Ans: 1 While it is important to rotate injection sites for insulin, it is preferred that the injection sites be rotated within one anatomic site (e.g., the abdomen) to prevent day-to-day changes in the absorption rate of the insulin. All of the other teaching points are appropriate. Focus: Supervision, prioritization

3. A nursing diagnosis for a patient with newly-diagnosed diabetes is Risk for Injury related to sensory alterations. Which key points should you 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 nonhealing skin breaks to your health care provider."

Ans: 1, 2, 5 Sensory alterations are the major cause of foot complications in diabetic patients, 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. Patients, family , or health care providers may trim toenails. Focus: Prioritization

22. You are 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 diabetes 2. Weight gain of 6 pounds 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

Ans: 1, 3 HHS often occurs in older adults with type 2 diabetes. Risk factors include taking diuretics and inadequate fluid intake. Weight loss (not weight gain) would be a symptom. While the patient's blood pressure is high, this is not a risk factor. A urine output of 50 to 75 mL/hr is adequate. Focus: Prioritization

9. In the care of a patient with type 2 diabetes, which actions can you delegate to a 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

Ans: 1, 3, 5 Giving the patient extra sweetener, recording oral intake, and checking blood pressure are all within the scope of practice of the UAP . Assessing shoe fit and patient teaching are not within the UAP's scope of practice. Focus: Assignment

19. The UAP reports to you that a patient with type 1 diabetes has a question about exercise. What important points would you 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. 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.

Ans: 1, 3, 5 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. When ketones are present in urine, the patient should not exercise because they 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. Warm-up and cool-down should be included in exercise to gradually increase and decrease the heart rate. Focus: Prioritization

18. While you are performing an admission assessment on a patient with type 2 diabetes, he tells you that he routinely drinks 3 beers a day . What is your 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?"

Ans: 2 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. Focus: Prioritization

10. In the emergency department during initial assessment of a newlyadmitted 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

Ans: 2 Rapid, deep respirations (Kussmaul respirations) are symptomatic of diabetic ketoacidosis (DKA). Hammer toe, as well as numbness and tingling, are chronic complications associated with diabetes. Decreased sensitivity and swelling (lipohypertrophy) occurs at a site of repeated insulin injections, and treatment involves teaching the patient to rotate injection sites. Focus: Prioritization

12. You are serving as preceptor to a nurse who has recently graduated and passed the RN licensure examination. The new nurse has only been on the unit for 2 days. Which patient should you assign to the new nurse? 1. 68-year-old with diabetes who is showing signs of hyperglycemia 2. 58-year-old with diabetes who has cellulitis of the left ankle 3. 49-year-old with diabetes who has just returned from the postanesthesia care unit after a below-knee amputation 4. 72-year-old with diabetes with DKA who is receiving IV insulin

Ans: 2 The new nurse is still on orientation to the unit. Appropriate patient assignments at this time include patients whose conditions are stable and not complex. Focus: Assignment

13. A patient with diabetes has hot, dry skin; rapid and deep respirations; and a fruity odor to his breath. As charge nurse, you observe a newlygraduated RN performing all the following patient tasks. Which one requires that you 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

Ans: 2 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 provider at this time. Focus: Prioritization

21. You are the preceptor for a senior nursing student who will teach a diabetic patient about self-care during sick days. For which statement by the student must you 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." 3. "To prevent dehydration, drink 8 ounces of sugar-free liquid every hour while you are awake." 4. "Continue to eat your meals and snacks at the usual times."

Ans: 2 Urine ketone testing should be done whenever the patient's blood glucose is greater than 240 mg/dL. 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. Focus: Supervision, delegation

17. Which actions can the school nurse delegate to UAPs who are 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. 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

Ans: 2, 4, 5 National guidelines published by the American Diabetes Association (ADA) indicate that administration of emergency treatment for hypoglycemia, obtaining blood glucose readings, and reminding children are appropriate tasks for non-health care professional personnel such as teachers, paraprofessionals, and unlicensed health care personnel. Assessments and education require more specialized education and scope of practice and should be done by the school nurse. Focus: Delegation

4. An LPN/LVN's assessment of two diabetic patients reveals all of these findings. Which would you instruct the LPN/LVN to report immediately? 1. Fingerstick glucose reading of 185 mg/dL 2. Numbness and tingling in both feet 3. Profuse perspiration 4. Bunion on the left great toe

Ans: 3 Profuse perspiration is a symptom of hypoglycemia, a complication of diabetes that requires urgent treatment. A glucose level of 185 mg/dL 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. Focus: Prioritization

24. The patient with type 2 diabetes is "nothing by mouth" (NPO) for a cardiac catheterization. An LPN/LVN who is administering medications to this patient asks you (the supervising RN) whether the patient should receive his ordered repaglinide (Prandin). What is your best response? 1. "Yes, because this drug will increase the patient's insulin secretion and prevent hyperglycemia." 2. "No, because this drug may cause the patient to experience gastrointestinal symptoms such as nausea." 3. "No, because this drug should be given 1 to 30 minutes before meals and the patient is NPO." 4. "Yes, because this drug should be taken 3 times a day whether the patient eats or not."

Ans: 3 Repaglinide is a meglitinide analog drug. These drugs are short-acting agents used to prevent postmeal blood glucose elevation. They should be given within 1 to 30 minutes before meals and cause hypoglycemia shortly after dosing when a meal is delayed or omitted. Focus: Supervision, delegation, prioritization

14. A patient has newly-diagnosed type 2 diabetes. Which action should you assign to an LPN/LVN instead of a 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

Ans: 3 The UAP's scope of practice includes checking vital signs and assisting with morning care. UAPs with special training can check the patient's glucose level before meals. 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. Focus: Assignment

1. You are 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 you 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

Ans: 3 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. Focus: Prioritization

20. The experienced UAP has been delegated to take vital signs and check fingerstick glucose on a diabetic patient who is postoperative. Which vital sign change would you instruct the UAP to report immediately? 1. Blood pressure increase from 132/80 mm Hg to 138/84 mm Hg 2. Temperature increase from 98.4° F (36.8° C) to 99° F (37.2° C) 3. Respiratory rate increase from 18 breaths/min to 22 breaths/min 4. Glucose increase from 190 mg/dL to 236 mg/dL

Ans: 4 An unexpected rise in blood glucose is associated with increased mortality and morbidity after surgical procedures. Current ADA guidelines recommend insulin protocols to maintain blood glucose levels between 140 and 180 mg/dL. Also, unexpected rises in blood glucose values may indicate wound infection. Focus: Delegation, supervision, prioritization

15. 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.

Ans: 4 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. Focus: Prioritization

2. A patient has newly-diagnosed type 2 diabetes. Which task should you delegate to a 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. Reminding the patient to check glucose level before each meal

Ans: 4 The UAP's role includes reminding patients about interventions that are already part of the plan of care. 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. Focus: Delegation, supervision, assignment

16. While working in the diabetes clinic, you obtain this information about an 8-year-old 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

Ans: 4 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 hypoglycemia. Focus: Prioritization

7. A UAP tells you 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 your 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. Talk with the patient about the relationship between illness and increased glucose levels.

Ans: 4 When a diabetic patient is ill or has surgery , glucose levels become elevated, and administration of insulin may be necessary . This is a temporary change that 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. Focus: Prioritization