Diabetes medications

Rosemary has been taking glargine (Lantus) to treat her condition. One of the benefits of glargine (Lantus) insulin is its ability to: A. Release insulin rapidly throughout the day to help control basal glucose. B. Release insulin evenly throughout the day and control basal glucose levels. C. Simplify the dosing and better control blood glucose levels during the day. D. Cause hypoglycemia with other manifestations of other adverse reactions.

Correct Answer: B. Release insulin evenly throughout the day and control basal glucose levels. Glargine (Lantus) insulin is designed to release insulin evenly throughout the day and control basal glucose levels. Insulin glargine is long-acting insulin injected once daily and provides a basal level of insulin throughout the day.

Alpha-Glucosidase Inhibitors acarbose miglitol (not usually given in the US) Delay absorption of complex carbohydrates in the intestine and slow entry of glucose into systemic circulation Does not increase insulin secretion Can be used alone or in combination with sulfonylureas, metformin, or insulin to improve glucose control

Hypoglycemia (risk increased if used with insulin or other antidiabetic agents) GI side effects (abdominal discomfort or distention, diarrhea, flatulence) Drug-drug interactions

Somogyi Effect

Normal or elevated blood glucose at bedtime, early morning hypoglycemia, and a subsequent increased blood glucose caused by the production of counter-regulatory hormones. Treated by decreasing evening (predinner or bedtime) dose of intermediate-acting insulin, or increasing bedtime snack.

Which medication causes fluid retention and is contraindicated for heart failure?

Pioglitazone.

long acting glargine (Lantus) detemir (Levemir)

Q24 h at the same time of day Used for basal dose Never mix

oral antidiabetics can be used with both type 1 and type 2 diabetes, true or false?

The answer is false. So oral antidiabetic agents should only be used with patients with type 2 diabetes. Patients with type 1 diabetes will require insulin.

Which of the following insulins can be administered intravenously? A. NPH B. Lantus C. Humulin R D. Novolog

The answer is C.

ALPHA GLUCOSE INHIBITORS - ACARBOSE (PRECOSE) Acarbose is an oral antidiabetic medication that belongs to the class alpha glucose inhibitors; it's used to help patients with type 2 diabetes control their blood sugar levels. It's usually taken 3 times a day with meals at the first bite of food

Acarbose mode of action Acarbose works to control blood sugar levels by inhibiting glucose absorption in the gastrointestinal tract. Acarbose will prevent absorption of carbs (i.e. glucose) in the GI tract. Acarbose side effects Possible side effects of acarbose include GI upset, hepatotoxicity, and anemia, as it may interfere with the body's intrinsic factor in the GI tract. Acarbose contraindications Acarbose is contraindicated for patients with gastrointestinal (GI) disorders. Acarbose's mode of action is in the GI tract, so if the GI tract is not functioning properly, the effectiveness of acarbose may be impaired.

What medication works by decreasing glucose absorption in the GI tract?

Acarbose.

A client was brought to the emergency room with complaints of slurring of speech, vomiting, dry mucosa, and dry skin turgor. Lab tests showing serum sodium 125 mEq/L and serum blood glucose of 350 mg/dL. Nurse Sophie will anticipate the physician to initially order which of the following intravenous solutions? A. 10% dextrose in water (D10W) B. 0.9% normal saline solution C. 5% dextrose in water (D5W) D. 0.45% normal saline solution

Correct Answer: B. 0.9% normal saline solution The client is experiencing diabetic ketoacidosis. Initial priority in the treatment is to restore the extracellular fluid volume through the intravenous administration of 0.9% normal saline at 15-20 ml/kg/h. Immediate fluid resuscitation is vital to correct hypovolemia, restore tissue perfusion, and to clear ketones. Hydration improves glycemic control independent of insulin.

Which of the following diabetes drugs acts by decreasing the amount of glucose produced by the liver? A. Alpha-glucosidase inhibitors B. Biguanides C. Meglitinides D. Sulfonylureas

Correct Answer: B. Biguanides Biguanides, such as metformin, lower blood glucose by reducing the amount of glucose produced by the liver. Metformin is a biguanide drug that reduces blood glucose levels by decreasing glucose production in the liver, decreasing intestinal absorption, and increasing insulin sensitivity.

Dr. Hugo has prescribed sulfonylureas for Rebecca in the management of diabetes mellitus type 2. As a nurse, you know that the primary purpose of sulfonylureas, such as long-acting glyburide (Micronase), is to: A. Induce hypoglycemia by decreasing insulin sensitivity. B. Improve insulin sensitivity and decrease hyperglycemia. C. Stimulate the beta cells of the pancreas to secrete insulin. D. Decrease insulin sensitivity by enhancing glucose uptake.

Correct Answer: C. Stimulate the beta cells of the pancreas to secrete insulin. Sulfonylureas such as glyburide are used only with patients who have some remaining pancreatic-beta cell function. These drugs stimulate insulin secretion, which reduces liver glucose output and increases cell uptake of glucose, enhancing the number of and sensitivity of cell receptor sites for interaction with insulin.

You are doing some teaching with a client who is starting on a sulfonylurea antidiabetic agent. The client mentions that he usually has a couple of beers each night and takes an aspirin each day to prevent heart attacks and/or strokes. Which of the following responses would be best on the part of the nurse? A. As long as you only drink two beers and take one aspirin, this should not be a problem B. The aspirin is alright but you need to give up drinking any alcoholic beverages C. Taking alcohol and/or aspirin with a sulfonylurea drug can cause the development of hypoglycemia D. Aspirin and alcohol will cause the stomach to bleed more when on a sulfonylurea drug

Correct Answer: C. Taking alcohol and/or aspirin with a sulfonylurea drug can cause the development of hypoglycemia Alcohol lowers blood glucose levels and disrupts the production of glucose in the liver. Sulfonylureas, when taken with alcohol, may produce a disulfiram-like reaction which may lead to flushing, hypotension, nausea, tachycardia, vertigo, and blurred vision. Metformin should be avoided in patients with a history of chronic alcohol use because they may be more predisposed to lactic acidosis.

A medication nurse is about to give insulin to a patient with diabetes mellitus. Upon reviewing the medications of the patient, which of the following would cause a further decrease in the blood glucose level of the patient? A. hydrochlorothiazide (Microzide) B. levothyroxine (Synthroid) C. carvedilol (Coreg) D. hydrocortisone (SoluCortef)

Correct Answer: C. carvedilol (Coreg) Carvedilol (Coreg) is a beta-blocker when given together with insulin would cause an increased hypoglycemic effect of insulin, resulting in a further decrease in the serum blood glucose level. Carvedilol has hyperglycemic potential when given orally for 5 days in normal albino rats. Though it may be beneficial in diabetics for various comorbid conditions, the glycemic control may worsen during its use in subjects with prediabetes, diabetes, high risk diabetes.

During the morning rounds, Nurse AJ accompanied the physician in every patient's room. The physician writes orders for the client with diabetes mellitus. Which order would the nurse validate with the physician? A. Use Humalog insulin for sliding scale coverage. B. Metformin (Glucophage) 1000 mg per day in divided doses. C. Administer regular insulin 30 minutes prior to meals. D. Lantus insulin 20U BID.

Correct Answer: D. Lantus insulin 20U BID. Lantus insulin is usually prescribed once a day so an order for BID dosing should be validated with the physician. Lantus is designed to give a steady level of insulin over 24 hours, even when you are not eating such as between meals and overnight. This helps keep blood glucose levels consistent during the day and at night.

Which insulin can be administered through continuous intravenous infusion? A. insulin glargine (Lantus) B. insulin aspart (Novolog) C. insulin detemir (Levemir) D. insulin Afrezza E. regular insulin (Novolin R)

Correct Answer: E. regular insulin (Novolin R) Regular insulin is a short-acting insulin that can be given intravenously in a continuous manner. For intravenous infusions, to minimize insulin adsorption to plastic IV tubing, flush the intravenous tube with a priming infusion of 20 mL from a 100 mL-polyvinyl chloride bag insulin every time a new intravenous tubing is added to the insulin infusion container.

What medication do you give an unconscious patient with hypoglycemia?

Glucagon.

Second-Generation Sulfonylureas glimepiride, glipizide, glyburide Stimulate beta cells of the pancreas to secrete insulin; may improve binding between insulin and insulin receptors or increase the number of insulin receptors Have more potent effects than first-generation sulfonylureas May be used in combination with metformin or insulin to improve glucose control

Hypoglycemia Mild GI symptoms Weight gain Drug-drug interactions (NSAIDs, warfarin, sulfonamides) Monitor patient for hypoglycemia. Monitor blood glucose and urine ketone levels to assess effectiveness of therapy. Patients at high risk for hypoglycemia: advanced age, renal insufficiency. When taken with beta-adrenergic blocking agents, may mask usual warning signs and symptoms of hypoglycemia. Instruct patients to avoid the use of alcohol. Contraindicated with sulfa allergy. Not recommended for elderly

Thiazolidinediones (or Glitazones) pioglitazone rosiglitazone Sensitize body tissue to insulin; stimulate insulin receptor sites to lower blood glucose and improve action of insulin May be used alone or in combination with sulfonylurea, metformin, or insulin

Hypoglycemia (risk increased with the use of insulin or other antidiabetic agents) Anemia Weight gain, edema Decrease effectiveness of oral contraceptives Possible liver dysfunction Drug-drug interactions Hyperlipidemia (has variable effect on lipids; pioglitazone may be preferred choice in patients with lipid abnormalities) Impaired platelet function Monitor blood glucose levels to assess effectiveness of therapy. Monitor liver function tests. Arrange dietary education to establish weight control program. Instruct patient taking oral contraceptives about increased risk of pregnancy.

Non-Sulfonylurea Insulin Secretagogues nateglinide repaglinide categorized as a meglitinide Stimulate pancreas to secrete insulin Can be used alone or in combination with metformin or thiazolidinediones to improve glucose control

Hypoglycemia/weight gain less likely than sulfonylureas Drug-drug interactions (with ketoconazole, fluconazole, erythromycin, rifampin, isoniazid) Monitor blood glucose levels to assess effectiveness of therapy. Has rapid action and short half-life Should be taken only if able to eat a meal immediately. Educate patients about symptoms of hypoglycemia. Monitor patients with impaired liver function and renal impairment. Has no effect on plasma lipids. Is taken before each meal. Check for interactions with other medications.

Biguanides (Metformin) Inhibit production of glucose by the liver Increase body tissue sensitivity to insulin Decrease hepatic synthesis of cholesterol (Type 2, children, prediabetic, pregnant)

Lactic acidosis Hypoglycemia if metformin is used in combination with insulin or other antidiabetic agents Drug-drug interaction GI disturbances Contraindicated in patients with impaired kidney or liver function, respiratory insufficiency, severe infection, or alcohol abuse Monitor for lactic acidosis and hypoglycemia. Monitor kidney function. Patients taking metformin are at increased risk for acute kidney injury and lactic acidosis with the use of iodinated contrast material for diagnostic studies; metformin should be stopped 48 h prior to and for 48 h after the use of contrast agent or until kidney function is evaluated and normal. Check for interactions with other medications.

Long-acting insulins - Insulin glargine (Lantus), insulin detemir (Levemir) Long-acting insulins like insulin glargine and insulin detemir are often used in the morning or at bedtime to help control blood sugar throughout the day.

Onset Long-acting insulins like insulin glargine and insulin detemir have an onset between 3 and 4 hours. Peak Long-acting insulins do not have a peak. This is by design, because they are meant to control blood sugar for the entire day. Duration Long-acting insulins last for about 24 hours.

Intermediate-acting insulin - NPH (Humulin N, Novolin N) Intermediate-acting insulin is often used to help control blood sugar between meals. Neutral Protamine Hagedorn (NPH) insulin is the most common intermediate-acting insulin that you will encounter.

Onset NPH insulin has an onset time of 2 to 4 hours, which means it takes 2-4 hours to start working after it's administered. Peak NPH insulin has a peak time between 4 and 12 hours. So, 4 to 12 hours after it's administered, NPH insulin is at its maximum effectiveness in the body. Duration NPH insulin has a duration between 12 and 18 hours, which means it is active about that long in the body. Neil Patrick Harris (NPH) is a hard-working actor of intermediate height. If you call him, he will be "on set" in 2-4 hours and he will stay there for 12-18 hours.

Metformin patient teaching

Patients taking metformin should take it with a meal. They should not use alcohol, because it may cause hypoglycemia. If a patient who is taking metformin gets scheduled for a procedure that will require them to be NPO (not eat) or a procedure that requires contrast dye, they should discontinue metformin 48 hours prior to that procedure. The reason why is because if they are not eating any food, they are not getting any glucose, and so continuing to take metformin would put them into a hypoglycemic state. Contrast dye used for X-rays may impair function in the kidneys for a small percentage of patients. Metformin may cause lactic acid buildup in patients with impaired kidney function, so that's why the two are not recommended together. Patients may need to take a B12 supplement if it is indicated; metformin has been correlated with B12 deficiencies.

THIAZOLIDINEDIONES - PIOGLITAZONE (ACTOS) Pioglitazone is an oral antidiabetic medication that belongs to the class thiazolidinediones; it's used to help patients with type 2 diabetes control blood sugar levels.

Pioglitazone mode of action Pioglitazone and other thiazolidinediones help to decrease blood glucose by decreasing insulin resistance and glucose production and increasing glucose uptake in the body's cells. Pioglitazone side effects The side effects of pioglitazone include fluid retention, elevated LDL, and hepatotoxicity. If you eat too much junk food, you might end up in the "Pig zone" (with fluid retention, edema and elevated LDLs). These are the key side effects with pioglitazone. Pioglitazone black box warning & contraindications Pioglitazone carries a black box warning due to the risk of congestive heart failure, and it is contraindicated in patients with heart failure.

Insulin Waning

Progressive rise in blood glucose from bedtime to morning. Treated by increasing evening (predinner or bedtime) dose of intermediate- or long-acting insulin, or instituting a dose of insulin before the evening meal if one is not already part of the treatment regimen.

Dawn Phenomenon

Relatively normal blood glucose until early morning hours when levels begin to rise. Treated by changing time of injection of evening intermediate-acting insulin from dinnertime to bedtime.

MEGLITINIDES: REPAGLINIDE (PRANDIN) The next category of oral antidiabetics you'll need to know are meglitinides. A key medication that falls within this class is repaglinide. They both end in "-inide"! Repaglinide is taken by patients with type 2 diabetes to lower blood sugar.

Repaglinide mode of action Meglitinides like repaglinide have essentially the same mode of action as sulfonylureas: they help to increase insulin release from the pancreas. Repaglinide side effects Side effects of repaglinide can include the hypoglycemia we discussed previously, as well as angina. We cover angina in the cardiovascular system section of our Medical-Surgical Nursing Flashcards. Repaglinide patient teaching When it comes to patient teaching for repaglinide, advise your patient to take this medication three times a day, and to eat within 30 minutes of taking the medication.

BIGUANIDES: METFORMIN (GLUCOPHAGE) The final oral antidiabetic class we'll cover in this article are biguanides, which include the common drug Metformin. Metformin is a drug commonly taken by patients with type 2 diabetes to lower blood sugar.

Metformin mode of action Metformin works by decreasing glucose production in the liver, and increasing the uptake of glucose by the body cells. Metformin side effects Side effects of metformin can include GI upset, a metallic taste, as well as lactic acidosis. Lactic acidosis Lactic acidosis is a form of metabolic acidosis marked by lactic acid buildup in the bloodstream. The signs and symptoms of lactic acidosis include diarrhea, dizziness, hypotension, weakness, and bradycardia. Cool Chicken A construction foreman (who takes metformin) drinks out of his metal thermos, then gets GI upset, a metal taste, and lactic acidosis.

You administered 5 units of Humalog at 0800. What is the ONSET and DURATION of this medication? A. Onset: 15 minutes, Duration: 3 hours B. Onset: 2 hours, Duration: 16 hours C. Onset: 30 minutes, Duration: 1 hour D. Onset: 2 hours, Duration: 24 hours

The answer is A. Humalog is a rapid-acting insulin. It has an onset: 15 minutes and duration: 3 hours Watch the YouTube video to learn the mnemonics on how to remember these times...very helpful.

A patient is scheduled to take 10 units of Humulin N at 1100. When is the patient most susceptible for hypoglycemia? A. 1900 B. 1300 C. 1130 D. 1500

The answer is A. Humulin N is an intermediate-acting insulin. The peak of this medication is 8 hours. Watch the YouTube video to learn the mnemonics on how to remember these times...very helpful.

A patient is scheduled to take a morning dose of Metformin. The patient is scheduled for surgery tomorrow. Which of the following nursing interventions are correct? A. Administer the medication as ordered. B. Hold the dose and notify the doctor for further orders. C. Administer the medication as ordered but hold the next day's dose. D. Check the patient's blood glucose prior to administering the medication.

The answer is B. Metformin (Glucophage) is held 48 hours prior to surgery (however a doctor's order is needed for this). Therefore, you should hold the dose and call the doctor for further orders.

A patient with diabetes is experiencing a blood glucose of 275 when waking. What is a typical treatment for this phenomenon? A. None, this is a normal blood glucose reading. B. The patient may need a night time dose of an intermediate-acting insulin to counteract the morning hyperglycemia. C. A bedtime snack may prevent this phenomenon. D. This is known as the Somogyi effect and requires decreasing the bedtime dose of insulin.

The answer is B. This is known as the DAWN PHENOMENON and is best treated with a night time dose of an intermediate-acting insulin to counteract the morning hyperglycemia.

A patient with diabetes asks you about what type of exercise they should perform throughout the week. The best response is: A. Lifting weights B. Sprinting C. Swimming D. Jumping

The answer is C. Aerobic exercise is the best and swimming is the only option that is an aerobic exercise.

A patient is scheduled to take 7 units of Humulin R at 0830. You administer Humulin R at 0900 in the right thigh. When do you expect this medication to peak? A. 1300 B. 0930 C. 1100 D. 1700

The answer is C. Humulin-R is a SHORT-ACTING insulin which has a PEAK time of 2 hours. If you gave the medication at 0900...it would peak at 1100.

A patient has a blood glucose of 58 and is sweating, cold, and clammy. The patient is conscious. What is your next nursing intervention? A. Recheck the blood glucose in 5 minutes. B. Give the patient 15 grams of a complex carbohydrate. C. No intervention is needed because this is a normal blood glucose. D. Give the patient 15 grams of a simple carbohydrate.

The answer is D. Simple carbohydrates work faster than complex. Example of a simple carbohydrate would be 4 oz of fruit juice or soda, glucose tablet or gel, etc.

When is a patient most susceptible to hypoglycemic symptoms after the administration of insulin? A. Onset B. Peak C. Duration D. Duration & Peak

The answer is B.

Which of the following patient statements about the diabetic diet regime is correct? A. "I'll try to consume about 20% carbs and 40% fats on a daily basis." B. "Foods that are high in mono and poly fats are avocados, olives, and nuts." C. "Meats increase the glycemic index; therefore, I should only consume 5% of them on a daily basis." D. "I should completely avoid starchy vegetables like potatoes and corn."

The answer is B.

True or False: The Somogyi effect causes the patient to experience an increase in their blood glucose during the hours of 2-3 am. True False

The answer is FALSE. The Somogyi effect causes the patient to experience a DECREASE in their blood glucose during the hours of 2-3 am.

Third question, what oral antidiabetic agent carries a risk for lactic acidosis?

The answer is metformin.

Dipeptidyl Peptidase-4 (DPP-4) Inhibitors alogliptin linaglipitin saxagliptin sitagliptin vildagliptin Increase and prolong the action of incretin, a hormone that increases insulin release and decreases glucagon levels, with the result of improved glucose control

Upper respiratory infection Stuffy or runny nose and sore throat Headache Stomach discomfort and diarrhea Hypoglycemia, if used with sulfonylurea Usually given once a day. Used alone or with other oral antidiabetic agents. Instruct patient about signs and symptoms of hypoglycemia and other adverse effects to report. Monitor kidney function.

Sodium-glucose co-transporter 2 (SGL-2) Inhibitors anagliflozin dapagliflozin empagliflozin Prevents the kidneys from reabsorbing glucose back into the blood, therefore lowering glucose by releasing glucose into the urine

Urinary tract infections Hypoglycemia May increase LDL and HDL cholesterol Should be taken once daily before first meal in the morning. Monitor for genital or urinary tract infections. Monitor kidney function Orthostatic hypertension, monitor potassium levels

Rapid-acting insulin Lispro (Humalog) Aspart (Novolog) Glulisine (Apidra)

Used for rapid reduction of glucose level, to treat postprandial hyperglycemia, or to prevent nocturnal hypoglycemia Onset 10-15 minutes

Short-acting (clear) Regular (Novolin R, Humulin R)

Usually given 15 min before a meal; may be taken alone or in combination with intermediate-acting insulin (clear is only kind given by IV) Onset 30-60 min

Incretin enhancers Pramlintide

-Mimic effects of incretins—hormones released into blood by intestine in response to food to signal insulin secretion and stop glucagon production -Reduce food intake by decreasing gastric emptying and increasing sense of "fullness" Can cause pancreantitis Used with insulin - give injections 2 inches apart

The nurse should emphasize which meals—and snacks—are being "covered" by which insulin doses.

the rapid- and short-acting insulins are expected to cover the increase in glucose levels after meals, immediately after the injection; the intermediate-acting insulins are expected to cover subsequent meals; and the long-acting insulins provide a relatively constant level of insulin and act as a basal insulin.

A patient has a blood glucose of 400. Which of the following medications could be the cause of this? A. Glyburide B. Atenolol C. Bactrim D. Prednisone

The answer is D.

SULFONYLUREAS PATIENT TEACHING GLIPIZIDE (GLUCOTROL), GLYBURIDE (DIABETA)

Advise patients to take a sulfonylurea medication 30 minutes before a meal. Patients definitely need to wear sunscreen when they go outside because of the side effect of photosensitivity. Sunscreen blocks UV rays so it can prevent the photoactivity reaction from occuring. Patients taking sulfonylureas should not drink alcohol because it can lead to hypoglycemia.

GLYCOGENOLYTIC AGENT - GLUCAGON (GLUCAGEN) Glucagon is a naturally-occurring hormone in the body that increases blood sugar levels. This hormone is covered in the Endocrine System section of our Medical-Surgical Nursing Flashcards which give an overview of the anatomy and physiology of each body system before diving into the diseases and disorders. Artificial glucagon is a medication known as a glycogenolytic agent that is given via the subcutaneous, intramuscular, or IV route for severe hypoglycemia when a patient is unable to take oral glucose.

After administering glucagon, provide patients with food as soon as they are able to safely swallow. Cool Chicken When the glucose is gone, take glucagon. Glucagon is also sometimes used as a diagnostic aid to slow down the motion in the bowels for radiology so clear pictures can be taken. Glucagon mode of action Glucagon increases blood sugar in three ways. Glucagon kicks off a pathway called glycogenolysis in which glycogen in the liver is converted into glucose and then released into the bloodstream. The reason food is given after glucagon is so that a patient's body can replenish its glycogen stores. Glucagon stimulates gluconeogenesis, which is production of new glucose. If you break down the word into its medical terminology parts, "Gluco" means relating to glucose, "neo" means new, and "genesis" means formation. Like glycogenolysis (#1), gluconeogenesis (#2) happens primarily in the liver. Glucagon causes adipose tissue to break down fat for use as energy. Glucagon side effects The side effects of glucagon may include GI upset.

SULFONYLUREAS: GLIPIZIDE (GLUCOTROL), GLYBURIDE (DIABETA) Sulfonylureas are a class of oral antidiabetic medications that includes glipizide and glyburide. Patients with type 2 diabetes may be prescribed sulfonylureas to keep their blood sugar down. Glipizide/glyburide - think of gleefully riding down a slide (with blood sugars coming down).

Contraindications Taking sulfonylureas is contraindicated for people who have a sulfa allergy. What is sulfa? Sulfonamide is a chemical group. Drugs made from this chemical group are called sulfonamides or sulfas; most commonly these are antibiotics. One example of a sulfonamide antibiotic is trimethoprim/sulfamethoxazole, which is covered in the immune system section of this Pharmacology series. Sulfonylureas mode of action Sulfonylureas work to bring a patient's blood sugar levels down by increasing the release of insulin from the pancreas. Sulfonylureas side effects Side effects of sulfonylureas include photosensitivity, GI upset, and hypoglycemia, like we talked about. Signs and symptoms of hypoglycemia include tachycardia, diaphoresis, shakiness, headache, and weakness.

Give Regular insulin by continuous I.V. infusion at 20 units/hr. The solution is 250 ml NS with 100 units of Regular insulin. What rate on the infusion pump will deliver the correct dose? Fill in the blank. Answer: ml/hr

Correct Answer: 50 ml/hr

After suffering an acute MI, a client with a history of type 1 diabetes is prescribed metoprolol (Lopressor) I.V. Which nursing interventions are associated with I.V. administration of metoprolol? Select all that apply. A. Monitor glucose levels closely. B. Monitor for heart block and bradycardia. C. Monitor blood pressure closely. D. Mix the drug in 50 ml of dextrose 5% in water and infuse over 30 minutes. E. Be aware that the drug is not compatible with morphine.

Correct Answer: A, B, & C. Metoprolol is a cardioselective beta-1-adrenergic receptor inhibitor that competitively blocks beta1-receptors with minimal or no effects on beta-2 receptors at oral doses of less than 100 mg in adults. It decreases cardiac output by negative inotropic and chronotropic effects. Option A: Metoprolol masks the common signs of hypoglycemia; therefore, glucose levels should be monitored closely in diabetic clients. The mechanism responsible for ?-blocker-induced hypoglycemia involves inhibition of hepatic glucose production, which is promoted by sympathetic nervous stimulation. In addition, adrenergic counter-regulation is diminished, resulting in a reduction in glycogenolysis. Option B: When used to treat an MI, metoprolol is contraindicated in clients with heart rates less than 45 beats/minute and any degree of heart block, so the nurse should monitor the client for bradycardia and heart block. Option C: Metoprolol masks common signs and symptoms of shock, such as decreased blood pressure, so blood pressure should also be monitored closely. Beta-blockers, including atenolol and metoprolol, may mask the signs of tachycardia and diaphoretic skin seen in patients in shock.

Mr. Wesley is newly diagnosed with Type I DM and is being seen by the home health nurse. The doctor's orders include: 1200 calorie ADA diet, 15 units NPH insulin before breakfast, and check blood sugar QID. When the nurse visits the patient at 5 pm, the nurse observes the man performing blood sugar analysis. The result is 50 mg/dL. The nurse would expect the patient to be: A. Anxiety, paleness, and pulse of 110 bpm B. Lethargic with hot dry skin and rapid deep respirations C. Alert and cooperative with BP of 130/80 mm Hg and respirations of 12 breaths per minute D. Short of breath, with distended neck veins and bounding pulse of 96 bpm

Correct Answer: A. Anxiety, paleness, and pulse of 110 bpm Hypoglycemia triggers the release of epinephrine (adrenaline), the "fight-or-flight" hormone which can cause symptoms such as confusion, paleness, and tachycardia. NPH insulin has a somewhat higher risk of hypoglycemia. Inadequate resuspension is thought to contribute to the high day-to-day variability in the pharmacodynamic and pharmacokinetic profile of NPH insulin, leading to hypoglycemia.

Nurse Robedee is teaching an underweight and emaciated client about the proper methods/techniques when giving insulin. Which one of the following shows a proper technique? A. Pinch the skin up and use a 90-degree angle B. Use a 45-degree angle with the skin pinched up C. Massage the area of injection after injecting the insulin D. Warm the skin with a warm towel or washcloth prior to the injection

Correct Answer: A. Pinch the skin up and use a 90-degree angle The best angle for a thin person is 90 degrees with the skin pinched up. The area is not massaged and it is not necessary to warm it. Injections are made into the subcutaneous tissue. Most individuals are able to lightly grasp a fold of skin, release the pinch, then inject at a 90° angle.

Dr. Wijangco orders insulin lispro (Humalog) 10 units for Alicia, a client with diabetes mellitus. When will the nurse administer this medication? A. When the client is eating B. Thirty minutes before meals C. Fifteen minutes before meals D. When the meal trays arrive on the floor

Correct Answer: A. When the client is eating The onset action for the insulin lispro (Humalog) is 10 to 15 minutes so it must be given when the client is eating to prevent hypoglycemia. Insulin lispro is a new type of insulin. It starts working sooner than other insulin types. It also reaches peak activity faster and goes away sooner. Option B: If taking Regular insulin or longer-acting insulin, the client should generally take it 15 to 30 minutes before a meal. Short-acting, such as Regular (R) insulin, starts working within 30 minutes and lasts about 5 to 8 hours. Option C: Each type of insulin works at a different speed and lasts for a different length of time. Quick-acting, such as insulin lispro (Humalog), begins to work very quickly (5 to 15 minutes) and lasts for 3 to 4 hours. Option D: It must be given when the client is eating, not when the meal trays arrive on the floor. Rapid-acting insulin analogs should be injected within 15 min before a meal or immediately after a meal. The most commonly recommended interval between injection of short-acting (regular) insulin and a meal is 30 min.

A patient received 6 units of regular insulin three (3) hours ago. The nurse would be most concerned if which of the following was observed? A. Kussmaul respirations and diaphoresis B. Anorexia and lethargy C. Diaphoresis and trembling D. Headache and polyuria

Correct Answer: C. Diaphoresis and trembling Diaphoresis and trembling indicate hypoglycemia and should be treated immediately. Neurogenic signs and symptoms can either be adrenergic (tremor, palpitations, anxiety) or cholinergic (hunger, diaphoresis, paresthesias). Identification of a hypoglycemic patient is critical due to potential adverse effects, including coma and/or death.

Nurse Matt makes a home visit to the client with diabetes mellitus. During the visit, Nurse Matt notes the client's additional insulin vials are not refrigerated. What is the best action by the nurse at this time? A. Instruct the client to label each vial with the date when opened. B. Tell the client there is no need to keep additional vials. C. Have the client place the insulin vials in the refrigerator. D. Have the client discard the vials.

Correct Answer: C. Have the client place the insulin vials in the refrigerator. Vials not in use should be refrigerated to preserve drug potency. Vials of insulin not in use should be refrigerated. Extreme temperatures (<36 or >86°F, <2 or >30°C) and excess agitation should be avoided to prevent loss of potency, clumping, frosting, or precipitation. Option A: Writing the date of opening on the vial is good practice, but does not address the need to refrigerate additional vials. Specific storage guidelines provided by the manufacturer should be followed. Insulin in use may be kept at room temperature to limit local irritation at the injection site, which may occur when cold insulin is used. Option B: The client should always have additional vials of insulin available. The patient should always have available a spare bottle of each type of insulin used. Although an expiration date is stamped on each vial of insulin, a loss in potency may occur after the bottle has been in use for >1 month, especially if it was stored at room temperature. Option D: There is no need to discard the vials. If uncertain about the potency of a vial of insulin, the individual should replace the vial in question with another of the same type. The person administering insulin should inspect the bottle before each use for changes (i.e., clumping, frosting, precipitation, or change in clarity or color) that may signify a loss in potency.

intermediate-acting (cloudy) NPH (Humulin N, Novolin N)

Food should be taken around the time of onset and peak Usually given BID - Given regardless of b/s Onset 1-1.5 hours

Rapid-acting insulins - Insulin lispro (Humalog), insulin aspart (Novolog) Rapid-acting insulins like insulin lispro and insulin aspart work quickly over a narrow and predictable window of time. It is usually administered before or after meals.

Onset The onset of rapid-acting insulin is 15 minutes. So rapid-acting insulin begins working in the body 15 minutes after it's taken. Peak The peak time of rapid-acting insulin happens around one hour after administration. So, one hour after administration, rapid-acting insulin is at its most effective in the body. Duration The duration of rapid-acting insulin is between 2 and 4 hours. So rapid-acting insulin is active in the body for about 2-4 hours after it's first taken. Nursing care If you have a patient requiring rapid-acting insulin, make sure their meal tray is readily available to help prevent hypoglycemia. If a patient were to take rapid-acting insulin and then not ingest a meal, the insulin would decrease the blood glucose already in the body rather than the new glucose from the food, resulting in hypoglycemia.

Short-acting insulins - Regular insulin (Humulin R, Novolin R) Short-acting or regular insulin, takes longer to begin working than rapid-acting insulin, but still works fairly quickly and is usually taken before meals.

Onset The onset of short-acting insulin is about 30 minutes, which means that it begins to work about 30 minutes after it's taken. Peak The peak time of short-acting insulin occurs between 2 and 3 hours. So, short-acting insulin is at its most effective 2-3 hours after administration. Duration The duration of short-acting insulin is between 3-6 hours, which means it will last in the body for 3-6 hours. Nursing care If you have a patient requiring short-acting insulin, make sure their meal tray is at least nearby. Unlike rapid-acting insulin, it does not need to be immediately available, but you should ensure it's delivered fairly soon. If a patient were to take short-acting insulin and not ingest a meal after the insulin's onset, blood glucose would likely drop too low. This access to a meal will help prevent hypoglycemia.

A patient newly diagnosed with diabetes is about to be discharged home. You are watching the patient administer insulin. Which of the following actions causes you to re-educate them? A. They massaged the site after administering the insulin. B. They injected into the fat of their thighs. C. They used an opposite side for injection compared to the last insulin injection. D. They engaged the safety after administering the medication.

The answer is A.

Which of the following statements are INCORRECT about exercise management for the diabetic patient? A. "I will check my blood glucose prior to exercise. If it is less than 200 I will eat a complex carb snack prior to exercising." B. "I plan on exercising for an extended period. So I will check my blood glucose prior, during, and after exercising." C. "My blood glucose is 268 and I have ketones in my urine. Therefore, I will avoid exercising today." D. All of the options are correct statements.

The answer is A.

A patient with Type 2 Diabetes is started on the medication Glyburide. Which of the following statements by the patient causes concern? A. "I will monitor my blood glucose regularly because I know this medication can cause a low blood sugar." B. "I will consume no more than 8 oz. of alcohol per week." C. "I will continue monitoring my diet and participating in exercise while taking this medication." D. "This medication works by stimulating the beta cells in the pancreas to make insulin."

The answer is B. Glyburide is a sulfonylureas diabetic medication and a patient should NEVER consume alcohol while taking this medication because it can cause severe hypoglycemia.

A patient is scheduled to take 5 units of Humulin R and 10 units of NPH. What is the proper way of mixing these insulins? A. These insulins cannot be mixed, therefore, should be drawn up in different syringes. B. Draw-up the Humulin R insulin first and then the NPH insulin. C. Draw-up 2.5 units of NPH, then 10 units of Humulin R, and then finish drawing up 2.5 units of NPH. D. Draw-up the NPH insulin first and then the Humulin R insulin.

The answer is B. Remember when drawing up regular and intermediate insulins...you draw-up clear (regular insulins) to cloudy (NPH intermediate). Remember the mnemonic R.N.

Which of the following insulins has no peak but a duration of 24 hours? A. NPH B. Novolog C. Lantus D. Humulin N

The answer is C. Lantus is the only option here that is a LONG-ACTING insulin which has NO peak and a 24 hour duration.

A patient taking the medication Precose asks when it is the best time to take this medication. Your response is: A. 1 hour prior to eating B. 1 hour after eating C. With the first bite of food D. At bedtime

The answer is C. Precose is an alpha-glucoside inhibitor that works by lowering the blood sugar by slowly breaking down starchy foods in the GI system which helps slowly rise the blood sugar. Therefore, it should be taken with the first bite of food.

what is a key side effect of many oral antidiabetic agents?

hypoglycemia