Chapter 38: Agents to Control Blood Glucose Levels

A client, being evaluated for diabetes, asks how a blood glucose test is used to diagnosis this disease. What is the nurse's best response?

"A fasting blood sugar result of 126 mg/dL (6.99 mmol/L) or more on two separate occasions is diagnostic of diabetes." Explanation: A major clinical manifestation of hyperglycemia is fasting blood glucose levels exceeding 126 mg/dL (6.99 mmol/L). A person with a fasting blood glucose level between 100 and 125 mg/dL (5.55 to 6.94 mmol/L) is said to have impaired fasting glucose or prediabetes. The normal hemoglobin A1C level is under 7.

A patient is taking chlorpropamide. The nurse warns the patient about the possibility of hypoglycemia within approximately which time frame after taking the drug?

3 to 4 hours Explanation: Chlorpropamide peaks in 3 to 4 hours, which would be the time for possible hypoglycemia.

The nurse is caring for a client who has been prescribed glyburide. Which factor, if identified in the client history, would cause the nurse to inform the health care provider of a contraindication to use?

Allergy to sulfonamides Explanation: Sulfonylureas are contraindicated in clients with hypersensitivity to them, with severe renal or hepatic impairment, and who are pregnant. A diagnosis of hypertension does not cause contraindication of sulfonylureas. The client should consume carbohydrates in association with the oral hypoglycemic agent. An increase in alkaline phosphatase does not result in the contraindication of glyburide.

A client receives a dose of insulin lispro at 8 AM. The nurse would be alert for signs and symptoms of hypoglycemia at which time?

Between 8:30 AM and 9:30 AM Explanation: With insulin lispro, peak effects would occur in 30 to 90 minutes or between 8:30 AM and 9:30 AM. Regular insulin peaks in 2 to 4 hours, so the nurse would be alert for signs and symptoms of hypoglycemia at this time, which would be between 10 AM and 12 noon. With insulin detemir, peak effects would occur in 6 to 8 hours, or between 2 PM and 4 PM. With NPH insulin, peak effects would occur in 4 to 12 hours, or between 12 noon and 8 PM.

The nurse is preparing to administer a mixture of 12 units regular insulin and 45 units NPH insulin to a client with a blood sugar of 378 mg/dL. After the nurse draws the medication into the syringe, what is the nurse's next action?

Check the dosage with another nurse. Explanation: After preparing the syringe with insulin, the nurse should then have the medication and dosage checked by a second nurse to make sure that it is correct. It is not necessary to recheck the client's blood sugar again. It is important to know when the client will be eating again; make sure that it is within the next 30 minutes. However, this is not the nurse's next step. Then the nurse will administer the insulin to the client.

The nurse is aware that premixed insulins (those that contain both regular and NPH insulin) are least effective in what type of client?

Client who has difficulty controlling his diabetes Explanation: Premixed insulins are least effective for clients who have difficulty controlling their diabetes, because it is difficult to individualize the dosages of each type of insulin. It is helpful to clients to use premixed insulin if they have difficulty drawing up their insulin, or seeing the markings on the syringe. The strict monitoring of the diet assists in keeping diabetes in good control.

A client newly diagnosed with type 1 diabetes asks the nurse why the client cannot just take a pill. The nurse would incorporate what knowledge when responding to this client?

Insulin is needed because the beta cells of the pancreas are no longer functioning. Explanation: Insulin is needed in type 1 diabetes because the beta cells of the pancreas are no longer functioning. With type 2 diabetes, insulin is produced, but perhaps not enough to maintain glucose control or the insulin receptors are not sensitive enough to insulin.

A client diagnosed with diabetic ketoacidosis has been admitted to the intensive care unit. The client is prescribed an intravenous insulin drip, so the nurse knows that what type of insulin will be administered?

Regular. Explanation: Regular insulin (insulin injection) has a rapid onset of action and can be given intravenously. Therefore, it is the insulin of choice during acute situations, such as DKA, severe infection or other illness, and surgical procedures. All the other options are administered subcutaneously.

A client's current condition requires rapid reduction of blood sugar levels. Which type of insulin will have the most rapid onset of action?

insulin lispro Explanation: Insulin lispro has a 15-minute onset of action. NPH, 70/30, and regular insulin have longer onsets of action, a later peak, and a longer duration of action.

A client newly diagnosed with diabetes reports "constant, insatiable thirst." When providing teaching to the client, how should the nurse explain the symptom?

"Excess glucose pulled more water through your kidneys and the increased urination caused thirst." Explanation: When large amounts of glucose are present, water is pulled into the renal tubule. This results in a greatly increased urine output (polyuria). The excessive loss of fluid in urine leads to increased thirst (polydipsia). Glucose does not directly affect the thirst center.

The nurse is discussing diabetes with a group of individuals who are at risk for the disease. Which statement by a participant indicates an understanding of the role of insulin in the disease?

"Insulin assists glucose molecules to enter the cells of muscle and fat tissues." Explanation: Insulin appears to activate a process that helps glucose molecules enter the cells of striated muscle and adipose tissue. It also stimulates the synthesis of glycogen by the liver, promotes protein synthesis, and helps the body store fat by preventing its breakdown for energy.

A nurse is providing client education to a 13-year-old girl who was just diagnosed with type 1 diabetes mellitus. Which statement by the client will alert the nurse that special instructions regarding insulin are necessary?

"I am on the middle school track team." Explanation: Because the client is on the track team, she will have increased exercise at various times that will require increased insulin and special instructions related to hypoglycemia that may come hours after she has ceased exercising. Walking two blocks every day and walking up stairs would not be considered increased physical exercise and would not be a factor. Wanting to have her mother administer the insulin is not uncommon for this age client, and the nurse would normally instruct both the mother and the daughter in the administration of the drug.

A 42-year-old male client is prescribed glargine insulin for management of his type 2 diabetes mellitus. The nurse caring for the client develops a teaching plan regarding glargine insulin therapy. Which statement made by the client indicates that the client needs additional teaching?

"The medication will peak in 3 hours." Explanation: Insulin glargine (rDNA) is characterized by a chemical structure that regulates its release from the SC tissue into the circulation, providing a relatively constant glucose-lowering effect with no pronounced peak of action over a 24-hour period. Glargine, unlike NPH, is a clear insulin, similar to regular insulin in its appearance. Extreme caution must be used not to confuse glargine with regular insulin because serious adverse effects, including hypoglycemia, can occur. Glargine must not be diluted or mixed with any other insulin or solution because its onset of action may be delayed, and the solution will become cloudy. Insulin glargine is administered subcutaneously once daily at bedtime.

The stress response triggered by illness will result in the increase secretion of what hormone? Select all that apply. -cortisol -glucagon -growth -thyroxine -epinephrine

-cortisol -glucagon -growth -epinephrine Explanation: Illness may affect diabetes control by triggering a stress response, resulting in increased secretion of glucagon, catecholamines, epinephrine, growth hormone, and cortisol and the presence of ketosis. Thyroxine, a thyroid hormone, is not affected.

The client is scheduled to get a breakfast tray at 07:00. At what time should the client receive a prescribed dose of insulin lispro?

06:45 Explanation: With short-acting insulins like lispro, aspart, or glulisine, it is important to inject the medication about 15 minutes before eating.

The nurse is educating a client who will be adding an injection of pramlintide to his insulin regimen. What information is most important for the nurse to share with this client to ensure safe medication administration?

Do not give pramlintide in the same site where insulin is administered. Explanation: Clients who take pramlintide should not be injected into the same site where insulin is administered.

Insulin binds with and activates receptors on cell membranes. Once insulin-receptor binding occurs, the membranes become highly permeable to glucose. Which action does this enable?

Entry of glucose into the cells Explanation: After insulin-receptor binding occurs, cell membranes become highly permeable to glucose and allow rapid entry of glucose into the cells.

Which would a nurse identify as an example of a sulfonylurea?

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

Which is the best indicator of overall diabetic control?

Glycosylated hemoglobin levels Explanation: The glycosylated hemoglobin indicates glucose bound to hemoglobin in red blood cells (RBCs) when RBCs are exposed to hyperglycemia. The binding is irreversible and lasts for the lifespan of RBCs (approximately 120 days). The test reflects the average blood sugar level during the previous 2 to 3 months. The goal is usually less than 7% (blood level 0.07). The range for people without diabetes is approximately 4% to 6% (blood level 0.04 to 0.06).

When describing the effects of incretins on blood glucose control to a group of students, which would an instructor include?

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

When administering insulin, what would be most appropriate?

Insert the needle at a 45-degree angle for injection. Explanation: The vial should be gently rotated and vigorous shaking is to be avoided to ensure uniform suspension of the insulin. Typically the area is pinched to allow access to the loose connective tissue layer. The needle is inserted at a 45-degree angle for subcutaneous administration. Gentle pressure should be applied at the injection site.

A nurse at a health care facility is assigned to administer insulin to the patient. Which intervention should the nurse perform before administering each insulin dose?

Inspect the previous injection site for inflammation. Explanation: The nurse should check the previous injection site before administering each insulin dose. The injection sites should be rotated to prevent lipodystrophy. Prefilled syringes should not be kept horizontally; they should be kept in a vertical or oblique position to avoid plugging the needle. The nurse checks for symptoms of myalgia or malaise when administration of metformin leads to lactic acidosis. Insulin should be kept at room temperature for administration. Insulin is refrigerated if it needs to be stored for up to three months for later use.

What is the expected action of sitagliptin on type 2 diabetes?

It slows the rate of inactivation of the incretin hormones. Explanation: Sitagliptin minimizes the rate of inactivation of the incretin hormones to increase hormone levels and prolong their activity. Sitagliptin does not block the S phase of the cell cycle. Sitagliptin is not a synthetically prepared monosodium salt nor does it inhibit hydrogen, potassium, and ATPase.

A client is prescribed sitagliptin. The nurse would expect to administer this drug by which route?

Oral Explanation: Sitagliptin is administered orally.

Which would be least appropriate when administering insulin by subcutaneous injection?

Massaging the site after removing the needle Explanation: Gentle pressure should be applied to the injection after the needle is withdrawn. Massaging could contribute to erratic or unpredictable absorption.

After teaching a group of students about the various methods for the delivery of insulin, the instructor determines that the teaching was successful when the students identify which method as most commonly used for administration?

Subcutaneous injection Explanation: Subcutaneous injection currently is the most common method for administering insulin.

A client diagnosed with type 2 diabetes several months ago has presented for a scheduled follow-up appointment. Which stated behavior most clearly indicates that the client has established effective health maintenance?

The client frequently checks blood glucose levels. Explanation: Vigilant blood glucose monitoring is imperative in the management of diabetes. This shows effective health maintenance even more clearly than exercising. Dietary modifications must be undertaken with care in people with diabetes to avoid health consequences. Explaining pathophysiology does not necessarily show effective health maintenance.

The nurse is providing care for several clients who have diabetes. Which client should the nurse monitor most closely for signs and symptoms of hypoglycemia?

a client who received 12 units of Humulin R 45 minutes ago Explanation: Administration of regular insulin will create a greater risk for hypoglycemia than metformin, which is used in the treatment of type 2 diabetes. A blood glucose level of 150 mg/dL is nominally elevated, and creates no particular risk for "rebound" hypoglycemia. Clients whose diabetes has been recently diagnosed must be monitored closely, but this does not mean that the client faces a particular risk for hypoglycemia.

The nurse is caring for a client who is taking glyburide as treatment for type 2 diabetes mellitus. The health care provider has added a corticosteroid to this client's medication regimen for treatment of a severe allergic reaction. The nurse knows that this drug combination may cause what adverse effect on this client?

hyperglycemia Explanation: Corticosteroids increase insulin needs, so the client may develop hyperglycemia.

Rosiglitazone is being considered for the treatment of diabetes in an adult client. Before the initiation of rosiglitazone therapy, the nurse should review what laboratory work recently drawn?

liver enzymes Explanation: Rosiglitazone has been associated with hepatotoxicity and requires monitoring of liver enzymes. Liver function tests (e.g., serum aminotransferase enzymes) should be checked before starting therapy and every 2 months for 1 year, then periodically. Platelets, d-dimer, and tests of renal function are less significant to the safety and efficacy of treatment.

The nurse is caring for a client who is taking insulin. The nurse suspects the client is experiencing hypoglycemia when the client displays what signs?

weakness, sweating, and decreased mentation. Explanation: Symptoms of hypoglycemia include shakiness, dizziness or light-headedness, sweating, nervousness or irritability, sudden changes in behavior or mood, weakness, pale skin, and hunger. The other signs are more consistent with hyperglycemia.

A client newly diagnosed with type 2 diabetes has attended educational sessions to provide insight into the diagnosis. Which of the client's statements should prompt the nurse to provide further teaching?

"I'm disappointed, but I take some solace in the fact that I won't ever have to have insulin injections." Explanation: Among people with type 2 diabetes, 20% to 30% require exogenous insulin at some point in their lives. Obesity is a major cause, and vigilant treatment can prevent future sequelae. The essence of type 2 diabetes is the pancreas' inability to meet insulin needs.

After teaching a group of students about the various insulin preparations, the instructor determines that the teaching was successful when the students identify that which type of insulin cannot be mixed with other types?

Detemir Explanation: Insulin detemir cannot be mixed in solution with any other drug, including other insulins. Regular, lente, and lispro can be mixed.

The health care provider has ordered a change of prescription from rapid-acting insulin to an intermediate-acting type. Which adverse effect must the nurse closely monitor for in the client?

Hypoglycemia Explanation: Changing the type of insulin requires caution, and the client should be carefully monitored for hypoglycemia or hyperglycemia, either of which may occur as the body adjusts to the different pharmacokinetics of the preparation. However, hypoglycemia may cause an increased sympathetic activity and manifest as tachycardia. Lipodystrophy is caused by the breakdown of subcutaneous fat because of repeated insulin injections at the same site. A change of insulin prescription is not known to cause hypotension.

The two major classifications of diabetes are type 1 and type 2. What is a distinguishing characteristic of type 1 diabetes?

Lifelong exogenous insulin is required. Explanation: Type 1 diabetes results from an autoimmune disorder that destroys pancreatic beta cells. Insulin is the only effective treatment for type 1 diabetes, because pancreatic beta cells are unable to secrete endogenous insulin and metabolism is severely impaired. Insulin cannot be given orally, because it is destroyed by proteolytic enzymes in the GI tract. Although the onset of type 1 diabetes frequently occurs in childhood, it can also occur in adulthood.

A nurse is caring for a patient with diabetes mellitus who is receiving an oral antidiabetic drug. Which of following ongoing assessments should the nurse perform when caring for this patient?

Observe the patient for hypoglycemic episodes. Explanation: As the ongoing assessment activity, the nurse should observe the patient for hypoglycemic episodes. Documenting family medical history and assessing the patient's skin for ulcers, cuts, and sores on the body is a pre-administration assessment activity performed by the nurse. Lipodystrophy occurs if the sites of insulin injection are not rotated.

A client diagnosed with type 1 diabetes suddenly reports feeling weak, shaky, and dizzy. What should be the nurse's initial response?

Perform a blood sugar analysis. Explanation: As long as the client is awake and verbally responsive, check the blood glucose level first. Hypoglycemia can make a client feel weak, confused, irritable, hungry, or tired, but assessment must precede interventions; this makes the other options inappropriate.

A patient at a health care facility has been prescribed diazoxide for hypoglycemia due to hyperinsulinism. What adverse reactions to the drug should the nurse monitor for in the patient?

Tachycardia Explanation: The nurse should monitor for tachycardia, congestive heart failure, sodium and fluid retention, hyperglycemia, and glycosuria as the adverse reactions in the patient receiving diazoxide drug therapy. Myalgia, fatigue, and headache are the adverse reactions observed in patients undergoing pioglitazone HCl drug therapy. Flatulence is one of the adverse reactions found in patients receiving metformin drug therapy. Epigastric discomfort is one of the adverse reactions observed in patients receiving acetohexamide drugs.

A nurse is working with a newly diagnosed diabetic client on understanding hypoglycemia and insulin reactions. Which action would be most important for the client to understand when planning the response to an insulin reaction?

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

The nurse is providing education to a client who has been prescribed therapy with an antidiabetic medication. During teaching, the nurse will caution the client against heavy intake of which herb?

Garlic Explanation: Garlic has been known to cause hypoglycemia when taken with antidiabetic medications. Anise, basil, and oregano are not noted to carry this risk.

A client has refused a scheduled dose of metformin, stating that he/she is worried about inducing hypoglycemia because his/her blood glucose level is currently 66 mg/dL (3.66 mmol/L). The nurse should convey what teaching points to the client?

Metformin does not cause hypoglycemia. Explanation: Experts prefer to call metformin an antihyperglycemic rather than a hypoglycemic because it does not cause hypoglycemia, even in large doses, when used alone. This fact about metformin makes the other statements inaccurate.

A nurse is preparing an in-service presentation for a group of staff members on diabetes. Which would the nurse include as the primary delivery system for insulin?

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

Which condition must be met in order for glyburide treatment to be effective?

The client must have functioning pancreatic beta cells. Explanation: Because glyburide stimulates pancreatic beta cells to produce more insulin, it is effective only when functioning pancreatic beta cells are present. The presence of normal blood glucose levels would render the medication unnecessary. Self-administration is common but not absolutely necessary.