Management of Diabetes

The nurse is assisting a patient with newly diagnosed type 2 diabetes to learn dietary planning as part of the initial management of diabetes. The nurse would encourage the patient to limit intake of which foods to help reduce the percent of fat in the diet?

Cheese is a product derived from animal sources and is higher in fat and calories than vegetables, fruit, and poultry. Excess fat in the diet is limited to help avoid macrovascular changes.

The nurse provides education to a patient with newly diagnosed type 1 diabetes mellitus. Which statement made by the patient indicates a need for further instruction?

A diabetic patient should adhere to an American Diabetes Association diet and insulin regimen. These patients should not self-regulate insulin unless directed to do so by their primary health care provider. The statements in the other answer options are all correct in regard to self-management of diabetes at home.

A patient with diabetes who takes long-acting and mealtime insulin calls the ambulatory center with complaints of an upper respiratory infection. The patient has a decreased appetite, fever, and cough. Which instructions should the nurse give the patient? Select all that apply.

Any illness or surgery can cause a regulatory hormonal response that may lead to hyperglycemia. Patients with diabetes and concurrent illnesses should check their blood sugar at least every four hours, despite current eating patterns, to monitor for hyperglycemia. Many clinics will ask a patient to report to his or her healthcare provider for two blood glucose readings over 300 mg/dL in a row, not just one. Common illnesses such as an upper respiratory illness or the flu can cause changes in glucose requirements. Patients should be encouraged to continue their insulin injectables as prescribed and monitor for hyperglycemia or hypoglycemia. These patients should supplement with carbohydrate-containing foods or beverages as necessary.

The nurse is educating the patient regarding administration of meal-time insulin, aspart. Which statement by the patient indicates correct knowledge of the onset of action of this medication?

Aspart is rapid-acting insulin, onsets within five minutes, and peaks within an hour. The patient is instructed to administer it when food is in front of him or her, making the option "I will administer aspart within 15 minutes of eating" correct. If the patient administers the aspart 30 or 60 minutes before the food arriving, the patient may experience hypoglycemia. The patient may have hyperglycemia if he or she waits 30 minutes until after eating to administer the insulin.

After admitting a patient with diabetic ketoacidosis (DKA) to the emergency department, which nursing intervention is a priority ?

Because fluid imbalance in a patient with DKA is potentially life threatening, the initial goal of therapy is to establish IV access and begin fluid and electrolyte replacement. Insulin is administered intravenously only after a potassium level is determined, because insulin administration may cause hypokalemia. Administration of oxygen and insertion of a Foley catheter may be necessary in the initial emergency management of DKA, but obtaining IV access must come first.

The nurse is preparing the care plan for a patient with diabetes who is on bromocriptine therapy. Which intervention included in the care plan will be beneficial for the patient?

Bromocriptine is a dopamine agonist that may cause orthostatic hypotension, which in turn causes the patient to become dizzy when changing position. Therefore, the nurse should assist the patient when changing position to prevent accidental falls. Bromocriptine does not reduce absorption of vitamin K. Hence, the nurse does not provide vitamin K-rich food to the patient. The nurse does not monitor thyroid hormone levels, because bromocriptine does not impair thyroid functioning. Bromocriptine does not increase the risk of myocardial infarction.

A patient with type 2 diabetes who takes metformin daily to manage blood sugar is scheduled for an intravenous pyelogram (IVP). Which question by the nurse is most important to ask the patient when preparing for the procedure?

During an IVP, contrast dye is injected so that the urinary system can be visualized. To reduce risk of kidney injury, metformin should be discontinued a day or two before the procedure and for 48 hours following the procedure. Medication administration adherence, dosage, and history are important to assess, but will not affect the interaction.

The nurse is teaching an insulin-dependent diabetic patient about the effects of exercise on blood glucose level. The American Diabetic Association (ADA) recommends moderate activity that expends 200-350 kcal/hr. When collaborating with the patient to develop a self-management plan, what examples of moderate activity does the nurse offer? Select all that apply.

Examples of moderate activity include bowling, walking briskly, and dancing. The ADA recommends at least 150 minutes per week of moderate activity. Fishing is considered a light activity in which approximately 100-200 kcal/hr are expended. Aerobic exercises are considered vigorous activity expending approximately 400-900 kcal/hr.

The nurse provides education to a patient with type 1 diabetes. Which statement made by the patient indicates a need for further instruction?

Fingerstick blood glucose testing should be performed before meals. Checking the blood glucose after meals will yield inaccurate results. This is of essential concern if the patient is basing insulin dosage on fingerstick blood glucose results. Having a snack nearby during exercise, eating meals and snacks at regular times, and eating high-fiber, low-fat foods are all correct in regard to diabetes management.

A patient presents with diabetic ketoacidosis (DKA). The nurse initiates the collaborative plan of care with the understanding that the initial goal of the treatment plan is:

Fluid imbalance is potentially life threatening for patients with DKA. The initial goal of therapy is to establish intravenous (IV) access and begin fluid replacement. Once urine output is established, electrolyte replacement will be addressed. Potassium levels will need to be monitored, because insulin therapy, which is needed to correct the hyperglycemia, may further reduce the potassium level. Insulin therapy will be used to lower the blood glucose gradually, to prevent rapid drops in serum glucose, which could lead to fluid shifts and the potential for cerebral edema. Ketosis results from the use of fat stores for energy, because excess glucose is not being transported to the cells and used as a source of energy. Patients with DKA often present with nausea and vomiting; oral nourishment may be limited until symptoms lessen.

The nurse is assigned to care for a patient with type 2 diabetes. To encourage the patient to become an active participant in his or her care, what action should the nurse take?

For teaching to be effective, the first step is assessing the patient. Teaching can be individualized once the nurse is aware of what a diagnosis of diabetes means to the patient. Food restrictions, nutritionist referral, and setting long-term goals can occur once the nurse is confident the patient understands what it means to have diabetes.

Which statements best describe glargine? Select all that apply.

Glargine is a long-acting (background) insulin that lacks a peak action time. Glargine is often administered once a day via subcutaneous injection. Mealtime insulin may also be added if glargine is not adequate to achieve glycemic goals. The medication is not administered orally with food and water. Glargine must not be diluted or mixed with other insulin or solution in the same syringe.

The nurse provides teaching to a patient that has received a prescription for a low-glycemic index (GI) diet due to poor control of diabetes mellitus (DM). The nurse recognizes that the patient needs further education when the patient makes what food choice?

Glycemic index (GI) is the term used to describe the rise in blood glucose levels after a person consumes a food containing carbohydrates. Foods with high GI raise glucose levels higher and more quickly than foods with a low GI. Cornflake cereal has a high GI of 119 and should be avoided. An apple has a GI of 52; regular milk has a GI of 27; baked beans have an intermediate GI of 69.

A patient with type 2 diabetes mellitus (DM) is prescribed an oral hyperglycemic agent. The nurse provides the patient with a list of food items with a high glycemic index (GI). What should the nurse include on the list?

Glycemic index (GI) is the term used to describe the rise in blood glucose levels after a person consumes a food containing carbohydrates. Foods with high GI raise glucose levels higher and more quickly than foods with a low GI. Cornflake cereal, white bread, and potatoes have a GI above 70. Baked beans, parboiled rice, oatmeal, sweet corn, and green pea soup have a medium GI ranging from 56 to 69. Apples, oat bran cereal, regular milk, and raw sweet potatoes have a low GI of about 55 or less.

The nurse has been teaching a patient newly diagnosed with diabetes mellitus to test his or her own blood glucose level. During evaluation of his or her technique, the nurse determines that the teaching has been adequate when the patient performs which task?

Hanging the hand down will promote blood flow to the finger and allow for an adequate blood sample. A blood sugar of 65 mg/dL is considered low and does not necessarily mean the diabetes is well controlled. The patient should select a site on the side of a fingertip, not on the center of a finger pad, and the site should be washed with soap and warm water.

The nurse has taught a patient who was admitted with diabetes, cellulitis, and osteomyelitis about the principles of foot care. The nurse determines that additional teaching is necessary when the patient makes which statement?

Hot water may injure tissue related to decreased sensation and should be avoided. Patients with diabetes mellitus should inspect the feet daily for broken areas that are at risk for delayed wound healing, avoid walking barefoot, and have a podiatrist for foot care.

To demonstrate an understanding of Somogyi effect, the nurse correctly identifies which defining characteristics? Select all that apply.

Hyperglycemia in the morning can be caused by the Somogyi effect, which can be stimulated by too much insulin in the evening. During the night, typically between 2:00 AM and 4:00 AM, hypoglycemia occurs, which stimulates a release in counterregulatory hormones in an attempt to raise the blood sugar. What results is rebound hyperglycemia resulting in higher blood sugar readings upon awakening. The Somogyi effect must be differentiated from dawn phenomenon, which also results in higher morning blood sugar readings. The treatment for Somogyi effect includes consuming a bedtime snack or reducing the evening insulin dose, whereas the treatment for dawn phenomenon is an increase in the evening insulin dose or an adjustment in the timing of the evening insulin dose. Not rotating insulin injection sites does not result in either the Somogyi effect or dawn phenomenon. In fact, current recommendations are to use the same anatomical injection site (e.g., the abdomen) for one week before moving to another anatomical injection site.

A patient diagnosed with type 1 diabetes has had elevated blood sugar readings each morning for the past four days. Which intervention by the nurse should be performed initially?

Hyperglycemia in the morning may be caused by the Somogyi effect. If a patient is experiencing morning hyperglycemia, checking blood glucose levels between 2:00 and 4:00 AM for hypoglycemia will help determine if the cause is the Somogyi effect. Diabetics should be given evening snacks to prevent hypoglycemia during the night, but glucose assessment is a priority to rule out the Somogyi effect. Injection sites are rotated to prevent lipodystrophy. An increased dose of evening insulin may cause further decrease in early morning glucose and increased rebound hyperglycemia.

The newly diagnosed patient with type 2 diabetes has been prescribed metformin. What should the nurse tell the patient to best explain how this medication works?

Metformin is a biguanide that decreases the rate of hepatic glucose production and augments glucose uptake by tissues, especially muscles. Sulfonylureas and meglitinides increase insulin production from the pancreas. α-glucosidase inhibitors slow the absorption of carbohydrate in the intestine. Glucagon-like peptide receptor agonists increase insulin synthesis and release from the pancreas, inhibit glucagon secretion, and decrease gastric emptying.

Which statement by a patient indicates an insufficient understanding of the prescribed medication metformin?

Metformin should be taken daily for diabetes control; it is not indicated for as-needed use. It should be taken with breakfast and may initially cause diarrhea, which will resolve.

After administering glucagon to an unconscious patient, the nurse should place the patient in which position?

Nausea is a common reaction after glucagon injection. The patient should be placed in the side-lying position to prevent aspiration should the patient vomit. The supine, high-Fowler's, and semi-Fowler's positions are not advisable because of the risk of aspiration of vomitus.

A nurse is caring for a patient with diabetes mellitus who is in an inpatient unit. The primary health care provider has ordered regular insulin. The nurse is preparing the medication for subcutaneous injection. What is the most effective site for subcutaneous injection of insulin?

The abdomen is the preferred injection site; it provides the fastest subcutaneous absorption. The thigh, upper arm, and buttock are other sites that may be used for subcutaneous injection, but the abdomen is the best site.

A nurse is providing education for a patient with a new diagnosis of type I diabetes mellitus. Therapy for the patient will require subcutaneous insulin injections several times per day. When teaching the patient how to administer subcutaneous insulin, what education is the most accurate?

Patient education for administration of insulin for diabetes should include teaching the patient to avoid intramuscular injections because of the rapid and unpredictable absorption that could result in hypoglycemia. The use of an alcohol swab on the site before self-injection is no longer recommended. Routine hygiene such as washing with soap and water is adequate. Patients should be taught to avoid injection sites that will be exercised, because doing so could increase body heat and circulation, increase the rate of insulin absorption, and speeding up the onset of action, resulting in hypoglycemia. Patients should be taught to rotate the injection within and between sites, not to use one site, to allow for better insulin absorption.

The nurse is reviewing diabetic self-care management with a patient newly diagnosed with diabetes. The patient is in need of further education when stating to the nurse:

Patients with diabetes are at great risk for skin breakdown because of peripheral vascular problems and peripheral neuropathy. Patients should avoid using rubbing alcohol on skin to prevent tissue damage. The best way to prevent foot ulcers is prevention and early detection. Inspecting the feet every day for cuts, abrasions, pressure areas, or sores is a good practice. Toenails should be cut with the rounded contour of the nail and not cut down the corners of the nail. Another complication of diabetes is retinopathy. Patients with a history of diabetes should have an eye examination annually by an ophthalmologist.

After discussing prevention of type 1 diabetes complications with the nurse, the patient is correct when making which statement?

Patients with diabetes who have albumin in their urine should receive angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor antagonists to treat hypertension, which would also delay the progression of nephropathy. Dietary fat intake will not affect kidney function. Hot water bottle use increases the risk of tissue damage because of the diabetic's neuropathy and delayed healing. Diabetics should have an eye examination once a year to screen for retinopathy.

A patient diagnosed with diabetes mellitus is suspected of having insulin resistance. The nurse identifies that which medication would be most beneficial for the patient?

Pioglitazone, a thiazolidinedione, is used to improve insulin sensitivity in patients having insulin resistance. Glipizide, a sulfonylurea, is prescribed to stimulate insulin production. Acarbose, an α-glucosidase inhibitor, is used to lower postprandial blood glucose. Repaglinide, a meglitinide, stimulates insulin production in the pancreas.

The nurse is monitoring a family caregiver who is learning to inject pramlintide prescribed for glucose control. The nurse should intervene when noting which caregiver action?

Pramlinitide is administered subcutaneously before major meals. Because of the variation of absorption from injection sites in the arm, only the thigh or abdomen are appropriate sites for this medication. Gently rolling an insulin vial before drawing up a dose aids in mixing insulin solution. To ease in withdrawal of the dose, adding equal amounts of air into the vial before removing the dose will equalize pressure within the vial. Pramlintide should not be mixed in the same syringe with any other insulin.

The nurse is evaluating the outcome of patient teaching regarding aspart insulin. The patient demonstrates an appropriate understanding when stating:

Rapid-acting insulins, such as aspart, are used to control postprandial blood glucose levels. The timing of insulin injection with meals is crucial. Rapid-acting insulin has a quick onset of approximately 15 minutes and should be injected within 15 minutes of mealtime. Short-acting insulin, such as Humulin-R, because of longer onset of action, can safely be administered 30 to 60 minutes before a meal. Rapid-acting insulin such as aspart can be mixed safely with intermediate-acting insulin in the same syringe. Long-acting insulin such as glargine and detemir should not be mixed with any other insulins. Because rapid acting insulins have a shorter duration of action, they are typically injected before meals.

A patient is prescribed lispro therapy. Related to meal times, when would the nurse instruct the patient to administer the insulin?

Rapid-acting synthetic insulin analogs, which include lispro (Humalog), aspart (NovoLog), and glulisine (Apidra), have an onset of action of approximately 15 minutes and should be injected within 15 minutes of mealtime. The rapid-acting analogs most closely mimic natural insulin secretion in response to a meal. Lispro is not administered on an empty stomach or simultaneously with a meal. Short-acting regular insulin, not rapid-acting synthetic insulin, is administered 30 to 45 minutes before a meal to ensure the onset of action coincides with meal absorption.

The patient received regular insulin 10 units subcutaneously at 8:30 PM for a blood glucose level of 253 mg/dL. The nurse plans to monitor this patient for signs of hypoglycemia at which time related to the insulin's peak action?

Regular insulin exerts peak action in two to five hours, making the patient most at risk for hypoglycemia between 10:30 PM and 1:30 AM. Rapid-acting insulin's onset is between 10 to 30 minutes, with peak action and hypoglycemia most likely to occur between 9:00 PM and 11:30 PM. With intermediate acting insulin, hypoglycemia may occur from 12:30 AM to 8:30 AM.

The patient received regular insulin eight units subcutaneously (SQ) at 0900. The nurse plans to monitor this patient for signs of hypoglycemia during which time?

Regular insulin exerts peak action in two to five hours, placing the patient at greatest risk for hypoglycemia between 1100 and 1400. At this time, the nurse should offer the patient a snack. 1000 and 1100, 1200 and 1300, and 1300 and 1500 are not consistent with peak action of insulin administered at 0900.

The nurse observes a return demonstration by a patient who is learning how to mix regular insulin and NPH insulin in the same syringe. Which action by the patient indicates the need for further teaching?

Regular insulin is always withdrawn first so it will not become contaminated with the NPH insulin. Injecting air into the NPH bottle first, removing air bubbles after drawing up the regular insulin, and injecting air equal to the desired dose of insulin are correct actions in regard to the mixture of regular and NPH insulin.

The patient has a prescription for repaglinide. The nurse instructs the patient to take the medication at which time?

Repaglinide is an oral antidiabetic agent that should be given any time from 30 minutes to just before meals. It is given on a fixed schedule rather than only when blood sugars are elevated. The medication will not be effective if administered after meals or at bedtime.

Which statement by the patient with diabetes mellitus indicates that further education regarding exercise is required?

Strenuous activity can be perceived by the body as a stress and cause an increase in blood sugar by the release of counterregulatory hormones when the blood sugar is elevated and ketosis is present. The American Diabetes Association recommends that people with diabetes exercise 30 minutes per day, five days per week. To prevent hypoglycemia, it is important to exercise about an hour after consuming a meal or eat small carbohydrate snacks every 30 minutes during exercise. Weight loss decreases insulin resistance, which can lower blood glucose.

A nurse is providing discharge teaching to a patient with a new diagnosis of type I diabetes mellitus who will need to give self-injections of insulin at home. What statement by the patient indicates to the nurse that the discharge teaching was effective?

Teaching the patient to rotate the injection within and between sites is important to allow for better insulin absorption. The lower forearm is not an injection site for subcutaneous insulin administration. The abdomen, arm, thigh, and buttock are the preferred sites. Intermediate-acting insulin is normally cloudy, and the patient should gently roll the bottle between the palms of hands to mix the insulin. The patient should push the plunger all the way down and leave the needle in place for 5 seconds to ensure that all of the insulin has been injected before removing the needle.

The patient with diabetes should consume fiber as part of a healthy diet. The current recommendation for persons with diabetes is

The American Diabetes Association (ADA) recommends that diabetics consume 25 to 30 grams of fiber daily. This is the same level recommended for the nondiabetics, because there is no evidence that a higher intake of fiber is essential. Forty to 45 grams is too much fiber for the patient to consume, and 10 to 25 grams is not enough fiber.

A patient's blood glucose level before breakfast is 324 mg/dL. The nurse reviews the electronic medical record and notes that the patient receives a high dose of insulin each evening at bedtime. The nurse recognizes that the patient's hyperglycemia is most likely due to which problem with insulin therapy?

The Somogyi effect occurs when a patient receives a high dose of evening/bedtime insulin that produces a decline in blood glucose levels during the night. As a result, counter regulatory hormones are released, stimulating lipolysis, gluconeogenesis, and glycogenolysis, which in turn produce rebound hyperglycemia. Lipodystrophy is atrophy or hypertrophy of the subcutaneous tissue. Allergic reactions related to insulin occur as local inflammatory reactions and do not produce hyperglycemia. The dawn phenomenon also is characterized by hyperglycemia that is present on awakening; however, it is caused by growth hormone and cortisol excretion during the early morning hours and is unrelated to the amount of insulin given at nighttime.

A nurse is caring for a patient on an inpatient unit with type I diabetes mellitus. The primary health care provider has ordered regular insulin to be administered. The nurse is preparing the medication for subcutaneous injection. The patient asks the nurse why the abdomen is the chosen site to inject the insulin. Which response by the nurse demonstrates an understanding of the choice of injection site?

The abdomen is the preferred site for subcutaneous injection of insulin because it has the fastest subcutaneous absorption. The reason that the abdomen is the preferred site for injection is not because it does not hurt; all injections are uncomfortable. The abdomen may be an easier site to access, but that is not the reason the abdomen is used as an injection site. The nurse should not use the same injection site for administration that the patient has been using for self-injection; instead, the nurse should rotate the injection within and between sites to allow for better insulin absorption.

The nurse is teaching a patient with type 2 diabetes about exercise as a method to control blood glucose levels. The nurse knows the patient understands when the patient elicits which exercise plan?

The best exercise plan for the person with type 2 diabetes is for 30 minutes of moderate activity five days per week and resistance training three times a week. Brisk walking is moderate activity. Fishing and teaching are light activity and running is considered vigorous activity.

A patient hospitalized with diabetes mellitus has become shaky, anxious, and diaphoretic. Which action should the nurse implement first?

The blood glucose level should be checked with the first signs of hypoglycemia because it can be reversed easily, but can be life threatening if not treated. In the hospital setting, it is convenient to check the blood glucose. A 15 g snack should be provided after the blood glucose has been determined to be low. The health care provider should be notified after the blood glucose level is known. The patient is exhibiting signs of decreased blood glucose. Administration of insulin will lower further the blood glucose.

A patient with type 1 diabetes mellitus reports feeling shaky and lightheaded. The patient's skin is pale and sweaty. The nurse should take what immediate action?

The described symptoms represent mild-to-moderate hypoglycemia. Rapid treatment involves providing the alert and awake patient with a rapid-dissolving buccal glucose tablet or, if unavailable, a glass of glucose-containing liquid such as orange juice. The patient is experiencing hypoglycemia when the blood sugar is already low. Therefore, insulin should not be given. Administering glucagon is not necessary; the patient is awake and able to take food and fluids orally. After consuming a simple sugar, the patient requires a complex carbohydrate snack and protein to sustain the blood glucose and prevent rebound hypoglycemia.

A patient calls the health care provider's office at 8:00 AM and states, "I just experienced an episode of low blood sugar, which responded to oral glucose tablets." To help identify the cause of the low blood sugar, an appropriate question the nurse should ask is:

The glucose-lowering effects of exercise can last up to 48 hours, so it is possible for hypoglycemia to occur after activity, particularly if exercise is at a greater intensity or time than normal. Asking the patient about activity level would be the most appropriate question for the nurse to ask. Ketones can be found in the urine with elevated blood glucose levels and may indicate the presence of diabetic ketoacidosis. Ketones would not be of concern with hypoglycemia. Taking a lower dose of insulin would result in higher blood glucose. Fever and illness can lead to hyperglycemia as well.

The nurse provides dietary instructions to a patient with type 1 diabetes mellitus. Which statement made by the patient indicates a need for further teaching?

The goal of dietary therapy for the patient with diabetes mellitus is to attain and maintain an ideal body weight and a stable blood glucose level. Each patient should be prescribed a specific caloric intake and insulin regimen to help him or her achieve this goal. Insulin dosage should not be increased to account for an increased caloric intake. A bedtime snack for people taking evening NPH insulin, planning for an occasional low-calorie dessert, and eating at scheduled times are all part of correct diabetes management.

The nurse is discussing a healthy eating plan for a patient with diabetes. Which should the nurse include in the teaching about diabetes and diet?

The nurse should inform the patient to eat carbohydrates when drinking alcohol to reduce the risk for alcohol-induced hypoglycemia. Nutritive and nonnutritive sweeteners may be included in a healthy meal plan in moderation. The amount of daily protein in the diet for people with diabetes should be 15% to 20% of the total calories consumed. High-protein diets are not recommended as a weight loss method for people with diabetes. There is no evidence that a person with diabetes should consume more fiber than an individual who does not have diabetes. The current recommendation for the general population is 25 to 30 g/day.

A nurse caring for a patient with type 1 diabetes encourages the patient to exercise regularly as part of diabetes management. What precautions should the patient take when exercising? Select all that apply.

The nurse should inform the patient to exercise one hour after meals when blood sugar levels are rising. The exercise program should be started gradually and increased slowly, with a warm-up and cool-down period. Patients using medications are at a risk for hypoglycemia when exercising and should always carry a fast-acting source of carbohydrate such as glucose tablets or hard candies or eat small carbohydrate snacks every 30 minutes when exercising. If blood glucose is less than or equal to 100 mg/dL, the patient should retest blood glucose levels after a 15-g carbohydrate snack. The patient should then exercise if glucose levels increase after 15 to 30 minutes.

A nurse in the outpatient setting is teaching a patient about the importance of self-monitoring of blood glucose (SMBG) using a glucometer. What should the nurse tell the patient? Select all that apply.

The nurse should instruct the patient to test blood glucose levels whenever hypoglycemia is suspected so that immediate action can be taken. The patient should test blood glucose before and after exercise to determine the effects of exercise on metabolic control. Blood sample should be taken from the side of the finger pad rather than near the center, because there are fewer nerve endings along the side of the finger. Blood glucose is generally tested two hours after a meal to determine if the bolus insulin dose was adequate for the meal. Blood glucose may also be tested before a meal by patients who use insulin pumps or multiple daily injections and base the insulin dose on the carbohydrates in a meal or make adjustments if the preprandial value is above or below target. Hands should be washed in warm water before the finger puncture is made in order to promote blood flow to the fingers.

Which statements are appropriate for the nurse to make to a patient newly diagnosed with Type I diabetes mellitus (DM)? Select all that apply.

The nurse should teach the patient to decrease dietary sugar intake, self-administer insulin, and regularly monitor blood glucose levels as prescribed. A high-fat diet increases the patient's cholesterol levels and may increase the blood sugar levels. Reduction of physical exercise can also lead to increase in blood glucose level.

The nurse is educating a diabetic patient about the use of premixed insulin neutral protamine hagedorn /regular 70/30. What should the nurse inform the patient about using this insulin?

The nurse should teach the patient to rotate the injection within one anatomic site, such as the abdomen, for at least one week before using a different site to allow for better absorption of insulin. It is important to gently roll the insulin bottle between the palms 10 to 20 times to warm the insulin and resuspend the particles. Injections must be administered at a 45- to 90-degree angle, depending on the thickness of the patient's fat pad. The fastest subcutaneous absorption is from the abdomen, followed by the arm, thigh, and buttock.

Who can serve as a health care proxy?

The patient may choose anyone to serve as a health care proxy. Proxies do not have to be a domestic partner, family member, or blood relative.

The patient states, "I want my partner to be able to make medical decisions in the event that I cannot." How should the nurse respond?

The patient requesting that his or her partner make medical decisions in the event that he or she cannot should have a durable power of attorney written. This is one type of advanced directive in which people, when they are competent, identify someone else to make decisions for them, should they lose their decision-making ability in the future. The Patient Self-Determination Act requires all health care facilities receiving Medicare and Medicaid to make available advanced directives allowing individuals to state their preferences or refusals of health care in the event that they are incapable of consenting for themselves. Responding to the patient with the statement of "How long have you been together?" is poor therapeutic communication. A living will allows an individual to state his or her preferences and refusals for end-of-life medical care.

The nurse has been teaching a patient with diabetes mellitus how to perform self-monitoring of blood glucose (SMBG). During evaluation of the patient's technique, the nurse identifies a need for additional teaching when the patient does what?

The patient should select a site on the sides of the fingertips, not on the center of the finger pad, because this area contains many nerve endings and would be unnecessarily painful. Washing hands, warming the finger, and knowing the results that indicate good control all show understanding of the teaching.

The nurse is evaluating the teaching session on nutrition for the newly diagnosed diabetic patient. Which statement indicates an understanding of the teaching?

The patient understands the need for a fast-acting sugar and the need to recheck in 15 minutes. Milk is not a fast-acting carbohydrate, so it will take longer for the low blood sugar to stabilize. The patient's statement about the hard candies does not indicate that the patient understands the need for 15 to 20 grams of carbohydrates. Rechecking blood sugar in 30 minutes is waiting too long to check blood sugar.

One of the unlicensed assistive personnel (UAP) reports to the nurse that a patient with diabetes is slow to respond, pale, and diaphoretic. What is the nurse's priority intervention?

The patient with diabetes is exhibiting signs and symptoms of hypoglycemia. The priority intervention at this time is to validate assessment findings with a bedside glucose reading. Although vital signs may add to assessment data findings, they are not as much a priority as validating hypoglycemia and initiating treatment. Because the patient is experiencing a change in level of consciousness, management of the hypoglycemia via oral nourishment is contraindicated. If the patient has an existing intravenous (IV) line, then treatment of documented hypoglycemia with intravenous dextrose may be indicated.

Because fluid imbalance in a patient with DKA is potentially life threatening, the initial goal of therapy is to establish IV access and begin fluid and electrolyte replacement. Insulin is administered intravenously only after a potassium level is determined, because insulin administration may cause hypokalemia. Administration of oxygen and insertion of a Foley catheter may be necessary in the initial emergency management of DKA, but obtaining IV access must come first.

The percent of dietary calories that should be eaten as carbohydrates is 55% to 60%. Protein calories make up 12% to 20% of calories; less than 30% of calories should derive from fat. Each meal should contain 45 to 60 grams of carbohydrates; protein intake is unchanged, and saturated fat should be minimized. Alcohol intake should also be limited to one drink per day for women and two per day for men.

A patient with type 2 diabetes mellitus (DM) receives a prescription for metformin. The nurse identifies that which statement is characteristic of this medication?

The primary action of metformin is to reduce glucose production by the liver. Metformin often causes weight loss instead of weight gain. Metformin can be administered in conjunction with sulfonylureas. Metformin is preferred for the initial management of type 2 diabetes.

A patient prescribed metformin complains of an "upset stomach" after ingestion of the medication. The nurse asks a student nurse what suggestion he or she would make. What is the most appropriate suggestion by the student?

The student nurse should suggest that the patient take metformin with food to decrease GI side effects. It is not within the nurse's scope of practice to prescribe medications such as diphenhydramine for nausea. Advising the patient to stop the medication immediately may result in a hyperglycemic response and should not be done without medication prescriber guidance. Getting the patient's blood glucose checked will not address the complaints of GI distress.

Which class of drugs used to treat diabetes mellitus (DM) may be referred to as "insulin sensitizers"?

Thiazolidinediones are a class of drugs used to treat diabetes mellitus (DM). They are often referred to as an "insulin sensitizers." This class of drugs improves insulin sensitivity, transport, and utilization at target tissues. Sulfonylureas increase insulin production by the pancreas. α-glucosidase inhibitors slow down absorption of carbohydrate in the small intestine. DPP-4 inhibitors enhance the activity of incretins, which stimulate release of insulin from pancreatic β-cells. This class of drug also decreases hepatic glucose production.

The nurse is caring for a patient diagnosed with diabetes mellitus (DM) who has developed insulin resistance. Which class of glucose-lowering agents can reduce insulin resistance?

Thiazolidinediones are often referred to as "insulin sensitizers." These agents improve insulin sensitivity, transport, and utilization at target tissues. Because they do not increase insulin production, thiazolidinediones do not cause hypoglycemia when used alone. Examples of thiazolidinediones include rosiglitazone and pioglitazone. DPP-IV inhibitors inactivate the hormone incretin. Dopamine agonists activate dopamine receptors and α-glucosidase inhibitors delay carbohydrate absorption in the small intestine.

A patient with type 2 diabetes has a urinary tract infection (UTI). The unlicensed assistive personnel (UAP) reported to the nurse that the patient's blood glucose is 642 mg/dL and the patient is hard to arouse. When the nurse assesses the urine, there are no ketones present. What collaborative care should the nurse expect for this patient?

This patient has manifestations of hyperosmolar hyperglycemic syndrome (HHS). Cardiac monitoring will be needed because of the changes in the potassium level related to fluid and insulin therapy and the osmotic diuresis from the elevated serum glucose level. Routine insulin would not be enough and exercise could be dangerous for this patient. Extra insulin will be needed. The type of antibiotic will not affect HHS. There will be a large amount of IV fluid administered, but it will be given slowly because this patient is older and may have cardiac or renal compromise, requiring hemodynamic monitoring to avoid fluid overload during fluid replacement.

After a teaching session with the registered nurse, the newly diagnosed patient with type 1 diabetes mellitus is correct when he or she makes which statement?

Type 1 diabetes is caused by destruction of pancreatic β-cells, which causes permanent insulin insufficiency and eventual absence. Weight loss and recovery will not affect insulin production. Exogenous insulin is not absorbed in the GI system and therefore must be given parenterally.

A patient with diabetes mellitus is scheduled for a fasting blood glucose level at 8:00 AM. The nurse instructs the patient to only drink water after what time?

Typically, a patient is prescribed to be nothing by mouth (NPO) for eight hours before a fasting blood glucose level. For this reason, the patient who has a laboratory draw at 8:00 AM should not have any food or beverages containing any calories after midnight.

A patient with diabetes mellitus is scheduled for a fasting blood glucose level at 8 AM. The nurse instructs the patient to fast for what period of time?

Typically, a patient is prescribed to be nothing by mouth (NPO) for eight hours before determination of the fasting blood glucose level. For this reason, the patient who has a laboratory draw at 8 AM should not have any food or beverages containing any calories after midnight. It is not necessary to fast longer than eight hours; 4 AM and 7 AM would not allow for sufficient time to fast for morning laboratory testing.

The nurse is caring for a patient in an outpatient diabetes clinic. Which statement by the patient indicates an understanding of the teaching?

When a patient with diabetes is ill, it is recommended he or she continues checking blood sugar every four hours and more frequently to prevent hyperglycemia and hypoglycemia during illness. The diabetic patient should adhere to the sick day rules, which indicate to continue with your basal dosing of insulin and continue to correct a finger stick blood sugar greater than 200. The patient also should be checking urine ketones for two blood sugars over 250 in a row.

The nurse is assessing a diabetic patient with complaints of night sweats, hyperglycemia, and headache on awakening. What should the nurse's assessment include? Select all that apply.

When assessing the patient with complaints of night sweats, hyperglycemia, and headache on awakening, the nurse must assess the patient for symptoms of Somogyi effect and dawn phenomenon. The nursing assessment must include insulin dose, injection sites, and variability in the time of meals or insulin administration. The nurse should ask the patient to measure and document bedtime, nighttime (between 2:00 AM and 4:00 AM), and morning fasting blood glucose levels on several occasions. These values help to adjust insulin dosage. A two-hour OGTT is performed to assess the risk of future diabetes. GI is the term used to describe the rise in blood glucose levels after a person has consumed a carbohydrate-containing food. OGTT and GI need not be assessed for this patient.

A patient with type 2 diabetes takes oral hypoglycemics and is admitted to the hospital with a urinary tract infection (UTI). The patient asks why insulin injections have been prescribed. What explanation should the nurse provide?

When the body is under stress, as in an acute illness, the need for insulin is more than oral hypoglycemics can provide. Insulin injections are usually required until the illness resolves. Insulin does not act synergistically with antibiotics, the patient did not need insulin at home, and oral hypoglycemics are not contraindicated in patients with UTIs.

To determine how well a patient's diabetes mellitus has been controlled over the past two to three months, what assessment parameter should the nurse review?

When the glucose level is increased, glucose molecules attach to hemoglobin in the red blood cells (RBCs). This attachment lasts for the life of the RBC, two to three months. Monitoring the numbers of these attachments makes it possible to assess the average blood glucose for the previous two to three months. Fasting blood glucose, oral glucose tolerance, and random fingerstick blood glucose tests are used to measure the current blood glucose level, which is different from the glycosylated hemoglobin level.

A college student is newly diagnosed with type 1 diabetes. The patient now has a headache, changes in vision, and is anxious, but does not have the portable blood glucose monitor with him or her. Which action should the campus nurse advise the patient to take?

When the patient with type 1 diabetes is unsure about the meaning of the symptoms he or she is experiencing, the patient should treat him- or herself for hypoglycemia to prevent seizures and coma from occurring. The patient also should be advised to check the blood glucose as soon as possible. The fat in the pizza and the diet soft drink would not allow the blood glucose to increase to eliminate the symptoms. The extra dose of rapid-acting insulin would further decrease the blood glucose.