Ch. 48 Diabetes Mellitus

Which nursing action can the nurse delegate to UAP who are working in the diabetic clinic? a. Measure the ankle-bracial index b. check for changes in skin pigmentation c. assess for unilateral or bilateral foot drop d. Ask the patient about symptoms of depression

A. measure the ankle-brachial index rationale: Checking systolic pressure at the ankle and brachial areas and calculating the ankle-brachial index is a procedure that can be done by UAP

The nurse determines a need for additional instruction when the patient with newly diagnosed type 1 diabetes says which of the following. a. I can have an occasional alcoholic drink if I include it in my meal plan. b. I will need a bedtime snack because I take an evening dose of NPH insulin. c. I can choose any foods, as long as I use enough insulin to cover the calories. d. I will eat something at meal times to prevent hypoglycemia, even if I am not hungry.

C. I can choose any foods, as long as I use enough insulin to cover the calories rationale: most patients with type 1 diabetes needs to plan diet choices very carefully.

Which action by the patient indicates that the home health nurses teaching about glargine and regular insulin has been successful. a. the patient administers the glargine 30 minutes before each meal b. the patients family prefills the syringes with the mix of insulins weekly. c. the patient draws up the regular insulin and then the glargine in the same syringe d. the patient disposes of the open vials of glargine and regular insulin after 4 weeks.

d. the patient disposes of the open vials of glargine and regular insulin after 4 weeks. rationale: Insulin can be stored at room temperature for 4 weeks.

The nurse has administered 4 oz of orange juice to an alert patient whose blood glucose was 62 mg/dL. 15 mins later the blood glucose is 67 mg/dL. Which action should the nurse take next? a. Give the patient 4 to 6 oz more orange juice b. Administer the PRN glucagon 1 mg IM c. Have the patient eat some peanut butter with crackers. d. Notify the HCP about the hypoglycemia

A. Give the patient 4 to 6 oz more orange juice. rationale: the "rule of 15" indicates that administration of quickly acting carbohydrates should be done 2 to 3 times for a conscious patient whose glucose remains less that 70 mg/dL before notifying the HCP

To monitor for complications in a patient with type 2 diabetes, which tests will the nurse in the diabetic clinic schedule at least annually. a. Chest x-ray b. blood pressure c. serum creatinine d. urine for microalbuminuria e. complete blood count CBC f. monofilament testing of the foot.

B, C, D, F rationale: Blood pressure, serum creatinine, urine testing for microalbuminuria, and monofilament testing of the foot are recommended at least annually to screen for possible microvascular and macrovascular complications of diabetes.

A few weeks after an 82 yr old with a new diagnosis of type 2 diabetes has been placed on metformin (Glucophage) therapy and taught about appropriate diet and exercise, the home health nurse makes a visit. Which finding by the nurse is most important to discuss with the health care provider. a. Hemoglobin A1C level is 7.9% b. Last eye exam was 18 months ago c. Glomerular filtration rate is decreased. d. Patient has questions about the prescribed diet.

C. Glomerular filtration rate is decreased. rationale: The decrease is renal function may indicate a need to adjust the dose of metformin or change to a different medication

A patient receives aspart (NovoLog) insulin at 8:00am. Which time will it be most important for the nurse to monitor for symptoms of hypoglycemia. a. 10:00am b. 12:00 am c. 2:00 pm d. 4:00 pm

a. 10:00 am. rationale: The rapid-acting insulins peak in 1 to 3 hours.

Which statement by the patient indicates a need for additional instruction in administering insulin. a. I need to rotate injection sites among my arms, legs, and abdomen daily. b. I can buy the 0.5ml syringes because the line markings will be easier to see. c. I should draw up the regular insulin first after injecting air into the NPH bottle. d. I do not need to aspirate the plunger to check for blood before injecting.

a. I need to rotate injection sites among by arms, legs, and abdomen. rationale: rotating sites is no longer recommended because there is more consistent insulin absorption when the same site is used consistently. The other patient statements are accurate.

A 32 yr old patient with diabetes is starting on intensive insulin therapy. Which type of insulin will the nurse discuss using for mealtime coverage. a. Lispro (humalog) b. Glargine (lantus) c. Detemir (Levemir) d. NPH (Humulin N)

a. Lispro (Humalog) rationale: rapid- or short-acting insulin is used for mealtime coverage for patients receiving intensive insulin therapy.

A 38 year old patient who has type 1 diabetes plans to swim laps daily at 1:00pm. The clinic nurse will plan to teach the patient to: a. check glucose level before, during, and after swimming. b. delay eating the noon meal until after the swimming class. c. increase the morning dose of neutral protamine Hagedorn (NPH) insulin d. time the morning insulin injection so that the peak occurs while swimming.

a. check glucose level before, during, and after swimming. rationale: the change in exercise will affect blood glucose, and the patient will need to monitor glucose carefully to determine the need for changes in diet and insulin administration.

Which information will the nurse include in teaching a female patient who has peripheral arterial disease, type 2 diabetes, and sensory neuropathy of the feet and legs. a. choose flat-soled leather shoes b. set heating pads of a low temp c. use callus remover for corns and calluses d. soak feet in warm water for an hour each day.

a. choose flat-soled leather shoes. rationale: the patient is taught to avoid heels and that leather shoes are preferred.

In order to assist an older diabetic patient to engage in moderate daily exercise, which action is most important for the nurse to take? a. Determine what type of activities the patient enjoys. b. remind the patient that exercise will improve self esteem c. teach the patient about the effects of exercise on glucose level. d. give the patient a list of activities that are moderate in intensity.

a. determine what type of activities the patient enjoys. rationale: because consistency with exercise is important, assessment for the types of exercise that the patient finds enjoyable is the most important action by the nurse in ensuring adherence to the exercise program.

Which question during the assessment of a diabetic patient will help the nurse identify autonomic neuropathy. a. do you feel bloated after eating. b. have you seen any skin changes. c. do you need to increase your insulin dosage when you are stressed d. have you noticed any painful new ulcerations or sores on your feet.

a. do you feel bloated after eating rationale: Autonomic neuropathy can cause delayed gastric emptying, which results in a bloated feeling for the patient.

A 54 yr old patient is admitted with diabetic ketoacidosis. Which admission order should the nurse implement first. a. Infuse 1 liter of normal saline per hour. b. give sodium bicarbonate 50 mEq IV push c. administer regular insulin 10 U by IV push d. start a regular insulin infusion at 0.1 units/kg/hr

a. infuse 1 liter of normal saline per hour. rationale: the most urgent patient problem is the hypovolemia associated with diabetic ketoacidosis (DKA), and the priority is to infuse IV fluids.

A 27 yr old patient admitted with diabetic ketoacidosis (DKA) has a serum glucose level of 732 mg/dL and serum potassium level of 3.1 mEq/L. Which action prescribed by the HCP should the nurse take first. a. Place the patient on a cardiac monitor b. administer IV potassium supplements. c. obtain urine glucose and ketone levels d. start an insulin infusion at 0.1 units/kg/hr.

a. place the patient on a cardiac monitor. rationale: hypokalemia can lead to potentially fatal dysrhythmias such as ventricular tachycardia and ventricular fibrillation, which would be detected with ECG monitoring

Which patient action indicates a good understanding of the nurses teaching about the use of an insulin pump. a. the patient programs the pump for an insulin bolus after eating b. the patient changes the location of the insertion site every week c. the patient takes the pump off at bedtime and starts it again each morning. d. the patient plans for a diet that is less flexible when using the insulin pump

a. the patient programs the pump for an insulin bolus after eating rationale: In addition to the basal rate of insulin infusion, the patient will adjust the pump to administer a bolus after each meal, with the dosage depending on the oral intake.

A female patient is scheduled for an oral glucose tolerance test. Which information from the patients health history is most important for the nurse to communicate to the HCP a. The patient uses oral contraceptives b. the patient runs several days a week c. the patient has been pregnant three times d. the patient has a family history of diabetes.

a. the patient uses oral contraceptives rationale: oral contraceptive use may falsely elevate oral glucose tolerance test (OGTT) values.

A 55 yr old female patient with type 2 diabetes has a nursing diagnosis of imbalanced nutrition: more than body requirements. Which goal is most important for this patient. a. The patient will reach a glycosylated hemoglobin level of less that 7% b. the patient will follow a diet and exercise plan that results in weight loss c. the patient will choose a diet that distributes calories throughout the day d. the patient will state the reasons for eliminating simple sugars in the diet.

a. the patient will reach a glycosylated hemoglobin level of less that 7%. rationale: The complications of diabetes are related to elevated blood glucose, and the most important patient outcome is the reduction of glucose to near-normal levels.

After change of shift report, which patient should the nurse assess first. a. 19 yr old with type 1 diabetes who has hemoglobin A1C of 12% b. 23 yr old with type 1 diabetes who has blood glucose of 40 mg/dL c. 40 yr old who is pregnant and whose oral glucose tolerance test is 202 mg/dL d. 50 yr old who uses exenatide (Byetta) and is complaining of acute abdominal pain

b. 23 yr old with type 1 diabetes who has a blood glucose of 40 mg/dL rationale: because the brain requires glucose to function, untreated hypoglycemia can cause unconsciousness, seizures, and death.

A diabetic patient who has reported foot pain at night receives a new prescription. Which information should the nurse teach the patient about amitriptyline (Elavil). a. Amintriptyline decreases the depression caused by your foot pain b. amitriptyline helps prevent transmission of pain impulses to the brain c. amitriptyline corrects some of the blood vessel changes that cause pain d. amitriptyline improves sleep and makes you less aware of nighttime pain.

b. amitriptyline helps prevent transmission of pain impulses to the brain. rationale: Tricyclic antidepressants decrease the transmission of pain impulses to the spinal cord and brain

A 34 yr old has a new diagnosis of type 2 diabetes. The nurse will discuss the need to schedule a dilated eye exam a. every 2 years b. as soon as possible c. when the patient is 39 yrs old d. within the first year after diagnosis.

b. as soon as possible rationale: because many patients have some diabetic retinopathy when they are first diagnosed with type 2 diabetes, a dilated eye exam is recommended at the time of diagnosis and annually thereafter

the nurse is preparing to teach a 43 yr old man who is newly diagnosed with type 2 diabetes about home management of the disease. Which action should the nurse take first? a. Ask the patients family to participate in the diabetes education program. b. assess the patients perception of what it means to have diabetes mellitus. c. Demonstrate how to check glucose using capillary blood glucose monitoring. d. discuss the need for the patient to actively participate in diabetes management.

b. assess the patients perception of what it means to have diabetes mellitus. rationale: before planning teaching, the nurse should assess the patients interest in and ability to self-manage the diabetes.

An active 28 yr old male with type 1 diabetes is being seen in the endocrine clinic. Which finding may indicate the need for a change in therapy. a. hemoglobin A1C level 6.2% b. blood pressure 146/88 c. heart rate at rest 58 bpm d. high density lipoprotein (HDL) level 65 mg/dL

b. blood pressure 146/88 rationale: to decrease the incidence of macrovascular and microvascular problems in patients with diabetes, the goal blood pressure is usually 130/80.

The nurse identifies a need for additional teaching when the patient who is self-monitoring blood glucose a. washes the puncture sit using warm water and soap. b. chooses a puncture site in the center of the finger pad. c. hangs the arm down for a minute before puncturing the site. d. Says the result of 120 mg indicates good blood sugar control.

b. chooses a puncture site in the center of the finger pad. rationale: The patient is taught to choose a puncture site at the side of the finger pad because there are fewer nerve endings along the side of the finger pad.

Which action should the nurse take after a 36 yr old patient treated with intramuscular glucagon for hypoglycemia regains consciousness. a. assess the patient for symptoms of hyperglycemia b. give the patient a snack of peanut butter and crackers c. have the patient drink a glass of orange juice or nonfat milk. d. administer a continuous infusion of 5% dextrose for 24 hours

b. give the patient a snack of peanut butter and crackers rationale: rebound hypoglycemia can occur after glucagon administration, but having a meal containing complex carbohydrates plus protein and fat will help prevent hypoglycemia.

Which information will the nurse include when teaching a 50 yr old patient who has type 2 diabetes about glyburide (Micronase, DiaBeta, Glynase). a. Glyburide decreases glucagon secretion from the pancreas b. Glyburide stimulates insulin production and release from the pancreas. c. Glyburide should be taken even if the morning glucose level is low. d. Glyburide should not be used for 48 hours after receiving IV contrast media.

b. glyburide stimulates insulin production and release from the pancreas. rationale: the sulfonylureas stimulate the production and release of insulin from the pancreas.

An unresponsive patient with type 2 diabetes is brought to the ED and diagnosed with hyperosmolar hyperglycemia syndrome (HHS). The nurse will anticipate the need to a. give a bolus of 50% dextrose b. insert a large-bore IV catheter c. initiate oxygen by nasal cannula d. administer glargine (Lantus) insulin

b. insert a large-bore IV catheter rationale: HHS is initially treated with large volumes of IV fluids to correct hypovolemia.

Which lab value reported to the nurse by the UAP indicates the most urgent need for the nurses assessment of the patient. a. bedtime glucose of 140 mg/dL b. noon blood glucose of 52 mg/dL c. fasting blood glucose of 130 mg/dL d. 2-hr postprandial glucose of 220 mg/dL

b. noon blood glucose of 52 mg/dL rationale: the nurse should assess the patient with a blood glucose level of 52 mg/dL for symptoms of hypoglycemia and give the patient carbohydrate-containing beverage such as orange juice.

The nurse is taking a health history from 29 yr old pregnant patient at the first prenatal visit. The patient reports no personal history of diabetes but has a parent who is diabetic. Which action will the nurse plan to take first. a. Teach the patient about administering regular insulin b. schedule the patient for a fasting blood glucose level c. discuss an oral glucose tolerance test for the 24th week of pregnancy d. provide teaching about an increased risk for fetal problems with gestational diabetes.

b. schedule the patient for a fasting blood glucose level rationale: patients at high risk for gestational diabetes should be screened for diabetes on the initial prenatal visit.

Which patient action indicates good understanding of the nurses teaching about administration of aspart (NovoLog) insulin. a. The patient avoids injecting the insulin into the upper abdominal area. b. The patient cleans the skin with soap and water before insulin administration c. the patient stores the insulin in the freezer after administering the prescribed dose d. The patient pushes the plunger down while removing the syringe from the injection site.

b. the patient cleans the skin with soap and water before insulin administration. rationale: Cleaning the skin with soap and water or with alcohol is acceptable. Insulin should not be frozen.

After change of shift report, which patient will the nurse assess first? a. 19 yr old with type 1 diabetes who was admitted with possible dawn phenomenon b. 35 yr old with type 1 diabetes whose most recent blood glucose reading was 230 mg/dL c. 60 yr old with hyperosmolar hyperglycemia syndrome who has poor skin turgor and dry oral mucosa. d. 68 yr old with type 2 diabetes who has several peripheral neuropathy and complains of burning foot pain.

c. 60 yr old with hyperosmolar hyperglycemic syndrome who has poor skin turgor and dry oral mucosa rationale: The patients diagnosis of HHS and signs of dehydration indicate that the nurse should rapidly assess for signs of shock and determine whether increased fluid infusion is needed.

After the nurse has finished teaching a patient who has new prescription for exenatide (Byetta), which patient statement indicates that the teaching as been effective. a. I may feel hungrier than usual when I take this medication b. I will not need to worry about hypoglycemia with the Byetta c. I should take my daily aspirin at least an hour before the Byetta d. I will take the pill at the same time I eat breakfast in the morning.

c. I should take my daily aspirin at least an hour before the Byetta. rationale: Since exenatide slows gastric emptying, oral medications should be taken at least an hour before the exenatide to avoid slowing absorption.

A 26 yr old patient with diabetes rides a bicycle to and from work everyday. Which site should the nurse teach the patient to administer the morning insulin. a. thigh b. buttock c. abdomen d. upper arm

c. abdomen rationale: patients should be taught not to administer insulin into a site that will be exercised because exercise will increase the rate of absorption.

When a patient with type 2 diabetes is admitted for a cholecystectomy, which nursing action can the nurse delegate to a licensed practical nurse. a. Communicate the blood glucose level and insulin dose to the circulating nurse in surgery b. discuss the reason for the use of insulin therapy during the immediate postoperative period c. administer the prescribed lispro (Humalog) insulin before transporting the patient to surgery d. plan strategies to minimize the risk for hypoglycemia or hyperglycemia during the postoperative period.

c. administer the prescribed lispro (Humalog) insulin before transporting the patient to surgery. rationale: LPN/LVN education and scope of practice includes administration of insulin.

Which statement by a nurse to a patient newly diagnosed with type 2 diabetes is correct. a. Insulin is not used to control blood glucose in patients with type 2 diabetes. b. Complications of type 2 diabetes are less serious than those of type 1 diabetes. c. changes in diet and exercise may control blood glucose levels in type 2 diabetes. d. type 2 diabetes is usually diagnosed when the patient is admitted with a hyperglycemic coma

c. changes in diet and exercise may control blood glucose levels in type 2 diabetes. rationale: For some patients with type 2 diabetes, changes in lifestyle are sufficient to achieve blood glucose control.

The HCP suspects the Somogyi effect in a 50 yr old patient whose 6:00 am blood glucose is 230 mg/dL. Which action will the nurse teach the patient to take? a. avoid snacking at bedtime. b. increase the rapid-acting insulin dose c. check the blood glucose during the night d. administer a large dose of long acting insulin.

c. check the blood glucose during the night. rationale: if the Somogyi effect is causing the patients increased morning glucose level, the patient will experience hypoglycemia between 2:00 and 4:00 am.

The nurse is assessing a 22 yr old patient experiencing the onset symptoms of type 1 diabetes. Which question is most appropriate for the nurse to ask. a. Are you anorexic b. is your urine dark colored c. have you lost weight lately d. do you crave sugary drinks

c. have you lost weight lately. rationale: weight loss occurs because the body is no longer able to absorb glucose and starts to break down protein and fat for energy.

A 48 yr old patient screened for diabetes at a clinic has a fasting plasma glucose level of 120 mg/dL. The nurse will plan to teach the patient about. a. self-monitoring of blood glucose b. using low doses regular insulin c. lifestyle changes to lower blood glucose d. effects of oral hypoglycemic medications.

c. lifestyle changes to lower blood glucose rationale: the patients impaired fasting glucose indicates prediabetes, and the patient should be counseled about lifestyle changes to prevent the development of type 2 diabetes.

A 26 yr old female with type 1 diabetes develops a sore throat and runny nose after caring for her sick child. The patient calls the clinic for advice about her symptoms and a blood glucose level of 210 mg/dL despite taking her usual glargine (Lantus) and lispro (Humalog) insulin. The nurse advises the patient to a. use only the lispro insulin until the symptoms are resolved. b. limit intake of calories until the glucose is less than 120 mg/dL c. monitor blood glucose every 4 hours and notify the clinic if it continues to rise. d. decrease intake of carbohydrates until glycosylated hemoglobin is less than 7%.

c. monitor blood glucose every 4 hours and notify the clinic if it continues to rise rationale: infection and other stressors increase blood glucose levels and the patient will need to test blood glucose frequently, treat elevations appropriately with lispro insulin, and call the HCP if glucose levels continue to be elevated.

A patient who was admitted with diabetic ketoacidosis secondary to a urinary tract infection has been weaned off an insulin drip 30 minutes ago. The patient reports feeling lightheaded and sweaty. Which action should the nurse take first. a. Infuse dextrose 50% by slow IV push b. Administer 1 mg glucagon subcutaneously c. obtain a glucose reading using a finger stick d. have the patient drink 4 ounces of orange juice

c. obtain a glucose reading using a finger stick rationale: the patients clinical manifestations are consistent with hypoglycemia and the initial action should be to check the patients glucose with a finger stick or order a stat blood glucose.

When a patient who takes metformin (Glucophage) to manage type 2 diabetes develops an allergic rash from an unknown cause, the HCP prescribes prednisone (Deltasone). The nurse will anticipate that the patient may a. need a diet higher in calories while receiving prednisone. b. develop acute hypoglycemia while taking the prednisone c. require administration of insulin while taking prednisone d. have rashes caused by metformin-prednisone interactions

c. require administration of insulin while taking prednisone. rationale: Glucose levels increase when patients are taking corticosteroids, and insulin may be required to control blood glucose.

Which information is most important for the nurse to report to the HCP before a patient with type 2 diabetes is prepared for a coronary angiogram. a. the patients most recent HbA1C was 6.5%. b. the patients admission blood glucose is 128 mg/dL c. the patient took the prescribed metformin (Glucophage) today. d. The patient took the prescribed captopril (Capoten) this morning.

c. the patient took the prescribed metformin (Glucophage) today. rationale: to avoid lactic acidosis, metformin should be discontinued a day or 2 before the coronary arteriogram and should not be used for 48 hours after IV contrast media are administered.

A patient with type 2 diabetes is scheduled for a follow-up visit in the clinic several months from now. Which test will the nurse schedule to evaluate the effectiveness of treatment for the patient. a. Urine dipstick for glucose b. oral glucose tolerance test. c. fasting blood glucose levels d. glycosylated hemoglobin level

d. glycosylated hemoglobin level rationale: the glycosylated hemoglobin (A1c or HbA1C) test shows the overall control of glucose over 90 to 120 days.

The nurse has been teaching a patient with type 2 diabetes about managing blood glucose levels and taking glipizide (Glucotrol). Which patient statement indicates a need for additional teaching. a. If I overeat at a meal, I will still take the usual dose of medication. b. Other medications besides the Glucotrol may affect my blood sugar. c. When I am ill, I may have to take insulin to control my blood sugar. d. My diabetes wont cause complications because i dont need insulin.

d. my diabetes wont cause complications because I dont need insulin.

A hospitalized diabetic patient received 38 U of NPH insulin at 7:00am. At 1:00 pm, the patient has been away from the nursing unit for 2 hours, missing the lunch delivery while awaiting a chest x-ray. To prevent hypoglycemia, the best action by the nurse is to a. Save the lunch tray for the patients later return to the unit. b. Ask that diagnostic testing area staff to start a 5% dextrose IV. c. send a glass of milk or orange juice to the patient in the diagnostic testing area. d. request that if testing is further delayed, the patient be returned to the unit to eat.

d. request that if testing is further delayed, the patient be returned to the unit to eat. rationale: consistency for mealtimes assists with regulation of blood glucose, so the best option is for the patient to have lunch at the usual time.

The nurse is interviewing a new patient with diabetes who receives rosiglitazone (Avandia) through a restricted access medication program. What is most important for the nurse to report immediately to the HCP a. The patients blood pressure is 154/92 b. the patient has a history of emphysema c. the patients blood glucose is 86 mg/dL d. the patient has chest pressure when walking.

d. the patient has chest pressure when walking. rationale: Rosiglitazone can cause myocardial ischemia. The nurse should immediately notify the HCP and expect orders to discontinue the medication

A 28 yr old male patient with type 1 diabetes reports how he manages his exercise and glucose control. Which behavior indicates that the nurse should implement additional teaching. a. The patient always carries hard candies when engaging in exercise b. The patient goes for a vigorous walk when his glucose is 200 mg/dL c. the patient has a peanut butter sandwich before going for a bicycle ride. d. the patient increases daily exercise when ketones are present in the urine.

d. the patient increases daily exercise when ketones are present in the urine. rationale: when the patient is ketotic, exercise may result in an increase in blood glucose level. Type 1 diabetic patients should be taught to avoid exercise when ketosis is present.

Which finding indicates a need to contact the HCP before the nurse administers metformin (Glucophage). a. the patients blood glucose level is 174 mg/dL b. the patient has gained 2lb (0.9kg) since yesterday. c. the patient is scheduled for a chest x-ray in an hour. d. the patients blood urea nitrogen (BUN) level is 52 mg/dL

d. the patients blood urea nitrogen (BUN) level is 52 mg/dL rationale: The BUN indicates possible renal failure, and metformin should not be used in patients with renal failure.