Ch 48 -- Diabetes Mellitus -- Med-Surg Nursing

what characterizes type 2 diabetes (select all that apply)? a. b-cells exhausion b. insulin resistance c. genetic predisposition d. altered production of adipokines e. inherited defect in insulin receptors f. inappropriate glucose production by the liver

ans: a,b,c,d,e,f

a nurse working in an outpatient clinic plans a screenig program for diabetes. what recommendations for screening should be included? a. OGTT for all minority populations every yr b. FPG for all individuals at age 45 and then every 3 yrs c. testing people under the age of 21 for islet cell antibodies d. testing for type 2 diabetes in all overweight or obese individuals

ans: b

in type 1 diabetes there is an osmotic effect of glucose when insulin deficiency prevents the use of glucose for energy. which classic symptom is caused by the osmotic effect of glucose? a. fatigue b. polydipsia c. poly phagia d. recurrent infections

ans: b

which class of oral glucose lowering agents (OA) is most commonly used for people with type 2 diabetes because it reduces hepatic glucose production and enhances tissue uptake of glucose? a. insulin b. biguanide c. meglitinide d. sulfonylurea

ans: b

why are the hormones cortisol, glucagon, epinephrine, and growth hormone referred to as counter regulatory hormones? a. decrease glucose production b. stimulate glucose output by the liver c. increase glucose transport into the cells d. independently regulate glucose level in the blood

ans: b

when caring for a patient with metabolic syndrome, the nurse should give the highest priority to teaching the patient about which treatment plan? a. achieving a normal weight b. performing daily aerobic exercise c. eliminating red meat from the diet d. monitoring the blood glucose periodically

ans: a

what are manifestations of diabetic ketoacidosis (DKA) (select all that apply)? a. thirst b. ketonuria c. dehydration d. metabolic acidosis e. kussmaul respirations f. sweet, fruity breath odor

ans: a,b,c,d,e,f

which tissues require insulin to enable movement of glucose into the tissue cells (select all that apply)? a. liver b. brain c. adipose d. blood cells e. skeletal muscle

ans: c, e

the nurse determines that a patient with a 2hr OGTT of 152 mg/dL has a. diabetes b. elevated A1C c. impaired fasting glucose d. impaired glucose tolerance

ans: d

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

ANS: A Rapid- or short-acting insulin is used for mealtime coverage for patients receiving intensive insulin therapy. NPH, glargine, or detemir will be used as the basal insulin. DIF: Cognitive Level: Apply (application) REF: 1125

A patient who has diabetes and reported burning foot pain at night receives a new prescription. Which information should the nurse teach the patient about amitriptyline ? a. Amitriptyline 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.

ANS: B Tricyclic antidepressants (TCAs) decrease the transmission of pain impulses to the spinal cord and brain. TCAs also improve sleep quality and are used for depression, but that is not the major purpose for their use in diabetic neuropathy. The blood vessel changes that contribute to neuropathy are not affected by TCAs. DIF: Cognitive Level: Apply (application) REF: 1150

the pt with diabetes has a blood glucose level of 248 mg/dL. which manifestations in the pt would the nurse understand as being related to this blood glucose level (select all that apply)? a. headache b. unsteady gait c. abdominal cramps d. emotional changes e. increase in urination f. weakness and fatigue

ans: a, c, e, f

the following interventions are planned for a patient with diabetes. which intervention can the nurse delegate to unlicensed assistive personnel (UAP)? a. discuss complications of diabetes b. check that the bath water is not too hot c. check the patient's technique for drawing up insulin d. teach the patient to use a meter for self monitoring of blood glucose

ans: b

The nurse is assessing a 55-yr-old female patient with type 2 diabetes who has a body mass index (BMI) of 31 kg/m2.Which goal in the plan of care is most important for this patient? a. The patient will reach a glycosylated hemoglobin level of less than 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.

ANS: A 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. A BMI of 30?9?kg/m2 or above is considered obese, so the other outcomes are appropriate but are not as high in priority. DIF: Cognitive Level: Analyze (analysis) REF: 1124

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

ANS: B Because the brain requires glucose to function, untreated hypoglycemia can cause unconsciousness, seizures, and death. The nurse will rapidly assess and treat the patient with low blood glucose. The other patients also have symptoms that require assessments or interventions, but they are not at immediate risk for life-threatening complications. DIF: Cognitive Level: Analyze (analysis) REF: 1146

Which patient action indicates good understanding of the nurse's 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.

ANS: B Cleaning the skin with soap and water is acceptable. Insulin should not be frozen. The patient should leave the syringe in place for about 5 seconds after injection to be sure that all the insulin has been injected. The upper abdominal area is one of the preferred areas for insulin injection. DIF: Cognitive Level: Apply (application) REF: 1128

An active 32-yr-old male who has type 1 diabetes is being seen in the endocrine clinic. Which finding indicates a need for the nurse to discuss a possible a change in therapy with the health care provider? a. Hemoglobin A1C level of 6.2% b. Blood pressure of 140/88 mmHg c. Heart rate at rest of 58 beats/minute d. High density lipoprotein (HDL) level of 65 mg/dL

ANS: B To decrease the incidence of macrovascular and microvascular problems in patients with diabetes, the goal blood pressure is usually 130/80 mm Hg. An A1C less than 6.5%, a low resting heart rate (consistent with regular aerobic exercise in a young adult), and an HDL level of 65 mg/dL all indicate that the patient's diabetes and risk factors for vascular disease are well controlled. DIF: Cognitive Level: Apply (application) REF: 1148

When a patient who takes metformin (Glucophage) to manage type 2 diabetes develops an allergic rash from an unknown cause, the health care provider prescribes prednisone. 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.

ANS: C Glucose levels increase when patients are taking corticosteroids, and insulin may be required to control blood glucose. Hypoglycemia is not a side effect of prednisone. Rashes are not an adverse effect caused by taking metformin and prednisone simultaneously. The patient may have an increased appetite when taking prednisone but will not need a diet that is higher in calories. DIF: Cognitive Level: Apply (application) REF: 1124

a 72 yr old woman is diagnosed with diabetes. what does the nurse recognize about the management of diabetes in the older adult? a. it is more difficult to achieve strict glucose control than in younger pts b. treatment is not warranted unless the pt develops severe hyperglycemia c. it does not include treatment with insulin because of limited dexterity and vision d. it usually requires that a younger family member be responsible for care of the pt

ans: a

a pt with diabetes calls the clinic because she is experiencing nausea and flu like symptoms. which advise from the nurse will be the best for this pt? a. administer the usual insulin dosage b. hold fluid intake until the nausea subsides c. come to the clinic immediately for evaluation and treatment d. monitor the blood glucose every 1 to 2 hrs and call if it rises over 150 mg/dL (8.3 mmol/L)

ans: a

a pt with diabetes is learning to mix regular insulin and NPH insulin in the same syringe. the nurse determines that additional teaching is needed when the patient does what? a. withdraws the NPH dose into the syringe first. b. injects air equal to the NPH does into the NPH vial first c. removes any air bubbles after withdrawing the first insulin d. adds air equal to the insulin dose into the regular vial and withdraws the dose

ans: a

individualized nutrition therapy for pts using conventional, fixed insulin regimens should include teaching the pt to a. eat regular meals at regular times b. restrict calories to promote moderate weight loss c. eliminate sucrose and other simple sugars from the diet d. limit saturated fat intake to 30% of dietary calorie intake

ans: a

to prevent hyperglycemia related to exercise, what should the nurse teach the pt using glucose-lowering agents about the best time for exercise? a. plan activity and food intake related to blood glucose levels. b. when blood glucose is greater thatn 250 mg/dL and ketones are present c. when glucose monitoring reveals that the blood glucose is in the normal range. d. when blood glucose levels are high, because exercise always has a hypoglycemic effect

ans: a

two days following a self-managed hypoglycemic episode at home, the pt tells the nurse that his blood glucose levels since the spisode have been between 80 and 90 mg/dL. which is the best response by the nurse? a. "that is a good range for your glucose levels." b. "you should call your health care provider because you need to have your insulin increased." c. "that level is too low in view of your recent hypoglycemia and you should increase your food intake." d. "you should take only half your insulin dosage for the next few days to get your glucose level back to normal."

ans: a

when teaching the patient with type 1 diabetes, what should the nurse emphasize as the major advantae of using an insulin pump? a. tight glycemic control can be maintained b. errors in insulin dosing are less likely to occur c. complications of insulin therapy are prevented d. frequent blood glucose monitoring is unnecessary

ans: a

during routine health screening, a pt is found to have fasting plasma glucose (FPG) of 132 mg/dL (7.33 mmol/L). at a follow up visit, a diagnosis of diabetes would be made based on which laboratory results (select all that apply)? a. A1C of 7.5% b. glycosuria of 3+ c. FPG greater than equal to 127 mg/dL (7.0 mmol/L) d. random blood glucose of 126 mg/dL (7.0 mmol/L) e. a 2hr oral glucose tolerance test (OGTT) of 190 mg/dL (10.5 mmol/L)

ans: a, c

the pt with type 2 diabetes is being put on acarbose (Precose) and wants to know about taking it. what should the nurse include in this pt's teaching (select all that apply)? a. take it with the first bite of each meal b. it is not used in pts with heart failure c. endogenous glucose production is decreased d. effectiveness is measured by 2hr postprandial glucose e. it delays glucose absorption from the gastrointestinal (GI) tract

ans: a, d, e

the nurse is teaching the patient with prediabetes ways to prevent or delay the development of type 2 diabetes. what information should be included (select all that apply)? a. maintain a healthy weight b. exercise for 60mins each day c. have blood pressure checked regularly d. assess for visual changes on a monthly basis e. monitor for polyuria, polyphagia, and polydipsia

ans: a, e

a patient with type 1 diabetes uses 20 U of Novolin 70/30 (NPH/regular) in the morning and at 6:00pm. when teaching the patient about this regimen, what should the nurse emphasize? a. hypoglycemia is most likely to occur before the noon meal. b. a set meal pattern with a bedtime snack is necessary to prevent hypoglycemia c. Flexibility in food intake is possible because insulin is available 24hrs a day. d. premeal glucose checks are required to determine needed changes in daily dosing

ans: b

a pt with newly diagnosed type 2 diabetes has been given a prescription to start an oral hypoglycemic medication. the pt tells the nurse she would rather control her blood sugar with herbla therapy. which action should the nurse take? a. teach the pt that herbal therapy is not safe and should not be used b. advise the pt to discuss using herbal therapy with her HCP before using it c. encourage the pt to give the prescriptive medication time to work before using herbal therapy d. teach the pt that if she takes herbal therapy, she will have to monitor her blood sugar more often.

ans: b

what should the goals of nutrition therapy for the patient with type 2 diabetes include? a. ideal body weight b. normal serum glucose and lipid levels c. a special diabetic diet using dietetic foods. d. five small meals per day with a bedtime snack

ans: b

when teaching the pt with diabetes about insulin administration, the nurse should include which instruction for the patient? a. pull back on the plunger after inserting the needle to check for blood b. consistently use the same size of insulin syringe to avoid dosing errors c. clean the skin at the injection site with an alcohol swab before each injection d. rotate injection sites from arms to thighs to abdomen with each injection to prevent lipodystrophies

ans: b

which statement best describes atherosclerotic disease affecting the cerebrovascular, cardiovascular, and peripheral vascular systems in pts with diabetes? a. it can be prevented by tight glucose control b. it occurs with a higher frequency and earlier onset than in the nondiabetic population c. it is caused by the hyperinsulinemia related to insulin resistance common in type 2 diabetes d. it cannot be modified by reduction of risk factors such as smoking, obesity, and high fat intake.

ans: b

what disorders and diseases are related to macrovascular complications of diabetes (select all that apply)? a. chronic kidney disease b. coronary artery disease c. microaneurysms and destruction of retinal vessels d. ulceration and amputation of the lower extremities e. capillary and arteriole membrane thickening specific to diabetes

ans: b, d

the pt with diabetes has been diagnosed wit autonomic neuropathy. what problems should the nurse expect to find in this pt (select all that apply)? a. painless foot ulcers b. erectile dysfunction c. burning foot pain at night d. loss of fine motor control e. vomiting undigested food f. painless myocardial infarction

ans: b, e, f

Which patient should the nurse plan to teach how to prevent or delay the development of diabetes? a. an obese 40 yr old hispanic woman b. a child whose father has type 1 diabetes c. a 34 yr old woman whose parents both have type 2 diabetes d. a 12 yr old boy whose father has maturity-onset diabetes of the young (MODY)

ans: c

a pt taking insulin has recorded fasting glucose levels above 200mg/dL (11.1 mmol/L) on awakening for the last five mornings. what should the nurse advise the pt to do first? a. increase the evening insulin dose to prevent the dawn phenomenon/ b. use a single dose insuin regimen with an intermediate acting insuin c. monitor the glucose level at bedtime, between 2:00am and 4:00 am, and on arising d. decrease the evening insulin dosage to prevent night hypoglycemia and the somogyi effect

ans: c

the nurse assess the technique of the patient with diabetes for self-monitoring of blood glucose (SMBG) 3 months after initial instruction. which error in the performance of SMBG noted by the nurse requires intervention? a. doing the SMBG before and after exercising b. puncturing the finger on the side of the finger pad c. cleaning the puncture site with alcohol before the puncture d. holding the hand down for a few mins before the puncture

ans: c

the nurse is assessing a newly admitted pt with diabetes. which observations should be addressed as the priority by the nurse? a. bilateral numbness of both hands b. stage II pressure ulcer on the right heel c. reapid respirations with deep inspiration d. areas of lumps and dents on the abdomen

ans: c

the nurse should observe the patient for symptoms of ketoacidosis when a. illnesses causing nausea and vomiting lead to biarbonate loss with body fluids b. glucose levels become so high that osmotic diuresis promotes fluid and electrolyte loss c. an insulin deficit causes the body to metabolize large amts of fatty acids rather than glucose for energy d. the pt skips meals after taking insulin, leading to rapid metabolism of glucose and breakdown of fats for energy

ans: c

what describes the primary difference in treatment for diabetic ketoacidosis (DKA) and hyperosmolar hyper glycemic syndrome (HHS)? a. DKA requires administration of bicarbonate to correct acidosis b. potassium replacement is not necessary in management of HHS c. HHS requires greater fluid replacement to correct the dehydration d. administration of glucose is withheld in HHS unitl the blood glucose reaches a normal level

ans: c

In addition to promoting the transport of glucose from the blood into the cell, what does insulin do? a. enhances the breakdown of adipose tissue for energy. b. stimulates hepatic glycogenolysis and gluconeogenesis. c. prevents the transport of triglycerides into adipose tissue d. increases amino acid transport into cells and protein synthesis.

ans: d

a pt with diabetes is found unconscious at home and a family member calls the clinic. after determining that a glucometer is not available, what should the nurse advise the famly member to do? a. have the pt drink some orange juice b. administer 10U of regular insulin subcutaneously c. call for an ambulance to transport the pt to a medical facility d. administer glucagon 1mg intramuscularly (IM) or subcutaneously

ans: d

following the teaching of foot care to a pt with diabetes, the nurse determines that additional instruction is needed when the patient makes which statement? a. "I should wash my feet daily with soap and warm water." b. "I should alwasy wear shoes to protect my feet from injury." c. "If my feet are cold, I should wear socks instead of using a heating pad." d. "I'll know if I have sores or lesions on my feet because they will be painful."

ans: d

lispro insulin (humalog) with NPH (humulin N) insulin is ordered for a pt with newly diagnosed type 1 diabetes. the nurse knows that when lispro insulin is used, when should it be admistered? a. only once a day b. 1 hr before meals c. 30 to 45 mins before meals d. at mealtime or within 15mins of meals

ans: d

the home care nurse should intervene to correct a patient whose insulin administration includes a. warming a prefilled refrigerated syringe in the hands before administration b. storing syringes prefilled with NPH and regular insulin needle up in the refrigerator. c. placing the insulin bottle currently in use in a small container on the bathroom countertop. d. mixing an evening dose of regular insulin with insulin glargine in one syringe for administration

ans: d

the pt with type 2 diabetes has had trouble controlling his blood glucose with several OAs but wants to avoid the risks of insulin. the HCP told him a medication will be prescribed that will increase insulin synthesis and release from the pancreas, inhibit glucagon secretion, and slow gastric emptying. the nurse knows this is which medication that will have to be injected? a. dopamine receptor agonist, bromocriptine (cycloset) b. dipeptidyl peptidase 4 (DPP-4) inhibitor, sitagliptin (Januvia) c. sodium glucose co-transporter 2 (SGLT2) inhibitor, canagliflozin (invokana) d. glucagon like peptide 1 receptor agonist, exenatide extended release (bydureon)

ans: d

which laboratory results would indicate that the patient has prediabetes? a. glucose tolerance result of 132 mg/dL (7.3 mmol/L) b. glucose tolerance result of 240 mg/dL (13.3 mmol/L) c. fasting blood glucose result of 80mg/dL (4.4 mmol/L) d. fasting blood glucose result of 120 mg/dL (6.7 mmol/L)

ans: d

In which order will the nurse take these steps to prepare NPH 20 units and regular insulin 2 units using the same syringe? (Put a comma and a space between each answer choice [A, B, C, D, E]). a. Rotate NPH vial. b. Withdraw regular insulin. c. Withdraw 20 units of NPH. d. Inject 20 units of air into NPH vial. e. Inject 2 units of air into regular insulin vial.

ANS: A, D, E, B, C When mixing regular insulin with NPH, it is important to avoid contact between the regular insulin and the additives in the NPH that slow the onset, peak, and duration of activity in the longer-acting insulin. DIF: Cognitive Level: Analyze (analysis) REF: 1126

Which question during the assessment of a patient who has diabetes 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?"

ANS: A Autonomic neuropathy can cause delayed gastric emptying, which results in a bloated feeling for the patient. The other questions are also appropriate to ask but would not help in identifying autonomic neuropathy. DIF: Cognitive Level: Apply (application) REF: 1150

To assist an older patient with diabetes to engage in moderate daily exercise, which action is most important for the nurse to take? a. Determine what types of activities the patient enjoys. b. Remind the patient that exercise improves 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.

ANS: A 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 an exercise program. The other actions may be helpful but are not the most important in improving compliance. DIF: Cognitive Level: Analyze (analysis) REF: 1134

Which nursing action can the nurse delegate to experienced unlicensed assistive personnel (UAP) who are working in the diabetic clinic? a. Measure the ankle-brachial index. b. Check for changes in skin pigmentation. c. Assess for unilateral or bilateral foot drop. d. Ask the patient about symptoms of depression.

ANS: A Checking systolic pressure at the ankle and brachial areas and calculating the ankle-brachial index is a procedure that can be done by UAP who have been trained in the procedure. The other assessments require more education and critical thinking and should be done by the registered nurse (RN). DIF: Cognitive Level: Apply (application) REF: 1152

A patient with diabetic ketoacidosis is brought to the emergency department. Which prescribed action should the nurse implement first? a. Infuse 1 L 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.

ANS: A The most urgent patient problem is the hypovolemia associated with diabetic ketoacidosis (DKA), and the priority is to infuse IV fluids. The other actions can be done after the infusion of normal saline is initiated. DIF: Cognitive Level: Analyze (analysis) REF: 1144

A patient receives aspart (NovoLog) insulin at 8:00 AM. At which time would the nurse anticipate the highest risk for hypoglycemia? a. 10:00 AM c. 2:00 PM b. 12:00 AM c. 2:00 PM d. 4:0 PM

ANS: A The rapid-acting insulins peak in 1 to 3 hours. The patient is not at a high risk for hypoglycemia at the other listed times, although hypoglycemia may occur. DIF: Cognitive Level: Understand (comprehension) REF: 1132

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 patient's family to participate in the diabetes education program. b. Assess the patient's 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.

ANS: B Before planning teaching, the nurse should assess the patient's interest in and ability to self-manage the diabetes. After assessing the patient, the other nursing actions may be appropriate, but planning needs to be individualized to each patient. DIF: Cognitive Level: Analyze (analysis) REF: 1139

An unresponsive patient with type 2 diabetes is brought to the emergency department and diagnosed with hyperosmolar hyperglycemic syndrome (HHS). The nurse will anticipate the need to a. give 50% dextrose. b. insert an IV catheter. c. initiate O2 by nasal cannula. d. administer glargine (Lantus) insulin.

ANS: B HHS is initially treated with large volumes of IV fluids to correct hypovolemia. Regular insulin is administered, not a long-acting insulin. There is no indication that the patient requires O2. Dextrose solutions will increase the patient's blood glucose and would be contraindicated. DIF: Cognitive Level: Apply (application) REF: 1145

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

ANS: B Most patients with type 1 diabetes need to plan diet choices very carefully. Patients who are using intensified insulin therapy have considerable flexibility in diet choices but still should restrict dietary intake of items such as fat, protein, and alcohol. The other patient statements are correct and indicate good understanding of the diet instruction. DIF: Cognitive Level: Apply (application) REF: 1132

The nurse is taking a health history from a 29-yr-old pregnant patient at the first prenatal visit. The patient reports that she has no personal history of diabetes, but her mother has diabetes. Which action will the nurse plan to take? a. Teach the patient about administering regular insulin. b. Schedule the patient for a fasting blood glucose level. c. Teach about an increased risk for fetal problems with gestational diabetes. d. Schedule an oral glucose tolerance test for the twenty-fourth week of pregnancy.

ANS: B Patients at high risk for gestational diabetes should be screened for diabetes on the initial prenatal visit. An oral glucose tolerance test may also be used to check for diabetes, but it would be done before the twenty-fourth week. Teaching plans would depend on the outcome of a fasting blood glucose test and other tests. DIF: Cognitive Level: Apply (application) REF: 1138

Which action should the nurse take after a 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.

ANS: B Rebound hypoglycemia can occur after glucagon administration, but having a meal containing complex carbohydrates plus protein and fat will help prevent hypoglycemia. Orange juice and nonfat milk will elevate blood glucose rapidly, but the cheese and crackers will stabilize blood glucose. Administration of IV glucose might be used in patients who were unable to take in nutrition orally. The patient should be assessed for symptoms of hypoglycemia after glucagon administration. DIF: Cognitive Level: Apply (application) REF: 1129

To monitor for complications in a patient with type 2 diabetes, which tests will the nurse in the diabetic clinic schedule at least annually (select all that apply)? 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

ANS: B, C, D, F 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. Chest x-ray and CBC might be ordered if the patient with diabetes presents with symptoms of respiratory or infectious problems but are not routinely included in screening. DIF: Cognitive Level: Apply (application) REF: 1148

After the nurse has finished teaching a patient who has a new prescription for exenatide (Byetta), which patient statement indicates that the teaching has been effective? a. "I may feel hungrier than usual when I take this medicine." 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."

ANS: C Because exenatide slows gastric emptying, oral medications should be taken at least 1 hour before the exenatide to avoid slowing absorption. Exenatide is injected and increases feelings of satiety. Hypoglycemia can occur with this medication. DIF: Cognitive Level: Apply (application) REF: 1132

Which laboratory value reported to the nurse by the unlicensed assistive personnel (UAP) indicates an urgent need for the nurse's 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

ANS: B The nurse should assess the patient with a blood glucose level of 52 mg/dL for symptoms of hypoglycemia and give the patient a carbohydrate-containing beverage such as orange juice. The other values are within an acceptable range or not immediately dangerous for a patient with diabetes. DIF: Cognitive Level: Apply (application) REF: 1152

The nurse is assessing a 22-yr-old patient experiencing the onset of symptoms of type 1 diabetes. To which question would the nurse anticipate a positive response? a. "Are you anorexic?" c. "Have you lost weight lately?" b. "Is your urine dark colored?" c. "Have you lost weight lately?" d. "Do you crave sugary drinks?"

ANS: C Weight loss occurs because the body is no longer able to absorb glucose and starts to break down protein and fat for energy. The patient is thirsty but does not necessarily crave sugar-containing fluids. Increased appetite is a classic symptom of type 1 diabetes. With the classic symptom of polyuria, urine will be very dilute. DIF: Cognitive Level: Apply (application) REF: 1121

A patient with diabetes rides a bicycle to and from work every day. Which site should the nurse teach the patient to use to administer the morning insulin? a. thigh. b. buttock. c. abdomen. d. upper arm.

ANS: C Patients should be taught not to administer insulin into a site that will be exercised because exercise will increase the rate of absorption. The thigh, buttock, and arm are all exercised by riding a bicycle. DIF: Cognitive Level: Apply (application) REF: 1128

A few weeks after an 82-yr-old patient 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 should the nurse promptly discuss with the health care provider? a. Hemoglobin A1C level is 7.9%. b. Last eye examination was 18 months ago. c. Glomerular filtration rate is decreased. d. Patient has questions about the prescribed diet

ANS: C The decrease in renal function may indicate a need to adjust the dose of metformin or change to a different medication. In older patients, the goal for A1C may be higher in order to avoid complications associated with hypoglycemia. The nurse will plan on scheduling the patient for an eye examination and addressing the questions about diet, but the area for prompt intervention is the patient's decreased renal function. DIF: Cognitive Level: Apply (application) REF: 1130

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. Fasting blood glucose c. Glycosylated hemoglobin b. Oral glucose tolerance c. Glycosylated hemoglobin d. Urine dipstick for glucose

ANS: C The glycosylated hemoglobin (A1C) test shows the overall control of glucose over 90 to 120 days. A fasting blood level indicates only the glucose level at one time. Urine glucose testing is not an accurate reflection of blood glucose level and does not reflect the glucose over a prolonged time. Oral glucose tolerance testing is done to diagnose diabetes but is not used for monitoring glucose control after diabetes has been diagnosed. DIF: Cognitive Level: Apply (application) REF: 1124

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 won't cause complications because I don't need insulin."

ANS: D The patient should understand that type 2 diabetes places the patient at risk for many complications and that good glucose control is as important when taking oral agents as when using insulin. The other statements are accurate and indicate good understanding of the use of glipizide. DIF: Cognitive Level: Apply (application) REF: 1130

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.

ANS: D When the patient is ketotic, exercise may result in an increase in blood glucose level. Patients with type 1 diabetes should be taught to avoid exercise when ketosis is present. The other statements are correct. DIF: Cognitive Level: Apply (application) REF: 1134

Which patient action indicates a good understanding of the nurse's 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 a diet with more calories than usual when using the pump.

ANS: A 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. The insertion site should be changed every 2 or 3 days. There is more flexibility in diet and exercise when an insulin pump is used, but it does not provide for consuming a higher calorie diet. The pump will deliver a basal insulin rate 24 hours a day. DIF: Cognitive Level: Apply (application) REF: 1129

A female patient is scheduled for an oral glucose tolerance test. Which information from the patient's health history is important for the nurse to communicate to the health care provider regarding this test? 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.

ANS: A Oral contraceptive use may falsely elevate oral glucose tolerance test (OGTT) values. Exercise and a family history of diabetes both can affect blood glucose but will not lead to misleading information from the OGTT. History of previous pregnancies may provide informational about gestational glucose tolerance but will not lead to misleading information from the OGTT. DIF: Cognitive Level: Apply (application) REF: 1124

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 each day." b. "I can buy the 0.5-mL syringes because the line markings will be easier to see." c. "I do not need to aspirate the plunger to check for blood before injecting insulin." d. "I should draw up the regular insulin first, after injecting air into the NPH bottle."

ANS: A 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 and indicate that no additional instruction is needed. DIF: Cognitive Level: Apply (application) REF: 1128

The nurse has administered 4 oz of orange juice to an alert patient whose blood glucose was 62 mg/dL. Fifteen minutes 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 (Glucagon) 1 mg IM. c. Have the patient eat some peanut butter with crackers. d. Notify the health care provider about the hypoglycemia.

ANS: A The "rule of 15" indicates that administration of quickly acting carbohydrates should be done two or three times for a conscious patient whose glucose remains less than 70 mg/dL before notifying the health care provider. More complex carbohydrates and fats may be used after the glucose has stabilized. Glucagon should be used if the patient's level of consciousness decreases so that oral carbohydrates can no longer be given. DIF: Cognitive Level: Analyze (analysis) REF: 1146

7. A patient who has type 1 diabetes plans to swim laps for an hour daily at 1:00 PM. 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.

ANS: A 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. Because exercise tends to decrease blood glucose, patients are advised to eat before exercising. Increasing the morning NPH or timing the insulin to peak during exercise may lead to hypoglycemia, especially with the increased exercise. DIF: Cognitive Level: Apply (application) REF: 1132

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

ANS: C Insulin can be stored at room temperature for 4 weeks. Glargine should not be mixed with other insulins or prefilled and stored. Short-acting regular insulin is administered before meals, and glargine is given once daily. DIF: Cognitive Level: Apply (application) REF: 1127

A 30-yr-old patient has a new diagnosis of type 2 diabetes. The nurse will discuss the need to schedule a dilated eye examination a. every 2 years. b. as soon as possible. c. when the patient is 39 years old. d. within the first year after diagnosis.

ANS: B Because many patients have some diabetic retinopathy when they are first diagnosed with type 2 diabetes, a dilated eye examination is recommended at the time of diagnosis and annually thereafter. Patients with type 1 diabetes should have dilated eye examinations starting 5 years after they are diagnosed and then annually. DIF: Cognitive Level: Apply (application) REF: 1149

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.

ANS: C For some patients with type 2 diabetes, changes in lifestyle are sufficient to achieve blood glucose control. Insulin is frequently used for type 2 diabetes, complications are equally severe as for type 1 diabetes, and type 2 diabetes is usually diagnosed with routine laboratory testing or after a patient develops complications such as frequent yeast infections. DIF: Cognitive Level: Understand (comprehension) REF: 1134

The health care provider 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 larger dose of long-acting insulin.

ANS: C If the Somogyi effect is causing the patient's increased morning glucose level, the patient will experience hypoglycemia between 2:00 and 4:00 AM. The dose of insulin will be reduced, rather than increased. A bedtime snack is used to prevent hypoglycemic episodes during the night. DIF: Cognitive Level: Apply (application) REF: 1129

A hospitalized diabetic patient received 38 U of NPH insulin at 7:00 AM. 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 patient's 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.

ANS: D Consistency for mealtimes assists with regulation of blood glucose, so the best option is for the patient to have lunch at the usual time. Waiting to eat until after the procedure is likely to cause hypoglycemia. Administration of an IV solution is unnecessarily invasive for the patient. A glass of milk or juice will keep the patient from becoming hypoglycemic but will cause a rapid rise in blood glucose because of the rapid absorption of the simple carbohydrate in these items. DIF: Cognitive Level: Analyze (analysis) REF: 1127

The nurse is interviewing a new patient with diabetes who takes rosiglitazone (Avandia). Which information would the nurse anticipate resulting in the health care provider discontinuing the medication? a. The patient's blood pressure is 154/92. b. The patient's blood glucose is 86 mg/dL. c. The patient reports a history of emphysema. d. The patient has chest pressure when walking.

ANS: D Rosiglitazone can cause myocardial ischemia. The nurse should immediately notify the health care provider and expect orders to discontinue the medication. A blood glucose level of 86 mg/dL indicates a positive effect from the medication. Hypertension and a history of emphysema do not contraindicate this medication. DIF: Cognitive Level: Apply (application) REF: 1130

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 on a low temperature. c. Use callus remover for corns or calluses. d. Soak feet in warm water for an hour each day.

ANS: A The patient is taught to avoid high heels and that leather shoes are preferred. The feet should be washed, but not soaked, in warm water daily. Heating pad use should be avoided. Commercial callus and corn removers should be avoided. The patient should see a specialist to treat these problems. DIF: Cognitive Level: Apply (application) REF: 1151

The nurse identifies a need for additional teaching when the patient who is self-monitoring blood glucose a. washes the puncture site 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.

ANS: B 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. The other patient actions indicate that teaching has been effective.

Which information will the nurse include when teaching a patient who has type 2 diabetes about glyburide ? 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 blood glucose level is low. d. Glyburide should not be used for 48 hours after receiving IV contrast media.

ANS: B The sulfonylureas stimulate the production and release of insulin from the pancreas. If the glucose level is low, the patient should contact the health care provider before taking glyburide because hypoglycemia can occur with this class of medication. Metformin should be held for 48 hours after administration of IV contrast media, but this is not necessary for glyburide. Glucagon secretion is not affected by glyburide. DIF: Cognitive Level: Apply (application) REF: 1130

A 26-yr-old female with type 1 diabetes develops a sore throat and runny nose after caring for her sick toddler. 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%.

ANS: C 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 health care provider if glucose levels continue to be elevated. Discontinuing the glargine will contribute to hyperglycemia and may lead to diabetic ketoacidosis (DKA). Decreasing carbohydrate or caloric intake is not appropriate because the patient will need more calories when ill. Glycosylated hemoglobin testing is not used to evaluate short-term alterations in blood glucose.

When a patient with type 2 diabetes is admitted for a cholecystectomy, which nursing action can the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)? 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.

ANS: C LPN/LVN education and scope of practice includes administration of insulin. Communication about patient status with other departments, planning, and patient teaching are skills that require RN education and scope of practice. DIF: Cognitive Level: Apply (application) REF: 1152

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 health care provider should the nurse take first? a. Place the patient on a cardiac monitor. b. Administer IV potassium supplements. c. Ask the patient about home insulin doses. d. Start an insulin infusion at 0.1 units/kg/hr.

ANS: A Hypokalemia can lead to potentially fatal dysrhythmias such as ventricular tachycardia and ventricular fibrillation, which would be detected with electrocardiogram (ECG) monitoring. Because potassium must be infused over at least 1 hour, the nurse should initiate cardiac monitoring before infusion of potassium. Insulin should not be administered without cardiac monitoring because insulin infusion will further decrease potassium levels. Discussion of home insulin and possible causes can wait until the patient is stabilized. DIF: Cognitive Level: Analyze (analysis) REF: 1146

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.

ANS: C The patient's clinical manifestations are consistent with hypoglycemia, and the initial action should be to check the patient's glucose with a finger stick or order a stat blood glucose. If the glucose is low, the patient should ingest a rapid-acting carbohydrate, such as orange juice. Glucagon or dextrose 50% might be given if the patient's symptoms become worse or if the patient is unconscious. DIF: Cognitive Level: Analyze (analysis) REF: 1135

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

ANS: C The patient's 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. The other patients also need assessment and intervention but do not have life-threatening complications. DIF: Cognitive Level: Analyze (analysis) REF: 1146

A patient screened for diabetes at a clinic has a fasting plasma glucose level of 120 mg/dL (6.7 mmol/L). The nurse will plan to teach the patient about a. self-monitoring of blood glucose. b. using low doses of regular insulin. c. lifestyle changes to lower blood glucose. d. effects of oral hypoglycemic medications.

ANS: C The patient's impaired fasting glucose indicates prediabetes, and the patient should be counseled about lifestyle changes to prevent the development of type 2 diabetes. The patient with prediabetes does not require insulin or oral hypoglycemics for glucose control and does not need to self-monitor blood glucose. DIF: Cognitive Level: Apply (application) REF: 1133

A patient who has type 2 diabetes is being prepared for an elective coronary angiogram. Which information would the nurse anticipate might lead to rescheduling the test? a. The patient's most recent A1C was 6.5%. b. The patient's blood glucose is 128 mg/dL. c. The patient took the prescribed metformin today. d. The patient took the prescribed captopril this morning.

ANS: C To avoid lactic acidosis, metformin should be discontinued a day or 2 before the coronary angiogram and should not be used for 48 hours after IV contrast media are administered. The other patient data will also be reported but do not indicate any need to reschedule the procedure. DIF: Cognitive Level: Apply (application) REF: 1130

Which finding indicates a need to contact the health care provider before the nurse administers metformin (Glucophage)? a. The patient's blood glucose level is 174 mg/dL. b. The patient is scheduled for a chest x-ray in an hour. c. The patient has gained 2 lb (0.9 kg) in the past 24 hours. d. The patient's blood urea nitrogen (BUN) level is 52 mg/dL.

ANS: D The BUN indicates possible renal failure, and metformin should not be used in patients with renal failure. The other findings are not contraindications to the use of metformin. DIF: Cognitive Level: Apply (application) REF: 1130