Pharmacology Chapter 57
A patient who has type 2 diabetes has a glycated hemoglobin A1c (HbA1c) of 10%. The nurse should make which change to the nursing care plan? A) Refer the patient to a diabetes educator because the result reflects poor glycemic control. B) Glycemic control is adequate; no changes are needed. C) Hypoglycemia is a risk; teach the patient the symptoms. D) Instruct the patient to limit activity and weekly exercise.
Correct: A Glycated hemoglobin (HbA1c) is a measure of plasma glucose levels on average over the previous 2- to 3-month period. The target value is 7% or lower. If it is greater than 7%, a diabetes educator is an additional resource who can facilitate lifestyle, exercise, and medication changes. Hypoglycemia is not a concern, because elevated HbA1c levels indicate poor glycemic control. Exercise should be part of an overall management program, because it counteracts insulin resistance.
A patient is scheduled to start taking insulin glargine (Lantus). On the care plan, a nurse should include which of these outcomes related to the therapeutic effects of the medication? A) Blood glucose control for 24 hours B) Mealtime coverage of blood glucose C) Less frequent blood glucose monitoring D) Peak effect achieved in 2 to 4 hours
Correct: A Insulin glargine is administered as a once-daily subcutaneous injection for patients with type 1 diabetes. It is used for basal insulin coverage, not mealtime coverage. It has a prolonged duration, up to 24 hours, with no peaks. Blood glucose monitoring is still an essential component to achieve tight glycemic control.
A teaching plan for a patient who is taking lispro (Humalog) should include which instruction by the nurse? A) "Inject this insulin with your first bite of food, because it is very fast acting." B) "The duration of action for this insulin is about 8 to 10 hours, so you'll need a snack." C) "This insulin needs to be mixed with regular insulin to enhance the effects." D) "To achieve tight glycemic control, this is the only type of insulin you'll need."
Correct: A Lispro is a rapid-acting insulin and has an onset of action of 15 to 30 minutes with a peak action of about 2 hours, not 8 to 10 hours. Because of its rapid onset, it is administered immediately before a meal or with meals to control the blood glucose rise after meals. Lispro insulin must be combined with an intermediate- or a long-acting insulin, not regular insulin (which also is a short-duration insulin), for glucose control between meals and at night. To achieve tight glycemic control, patients must combine different types of insulin based on their duration of action.
Before administering metformin (Glucophage), the nurse should notify the prescriber about which laboratory value? A) Creatinine (Cr) level of 2.1 mg/dL B) Hemoglobin (Hgb) level of 9.5 gm/dL C) Sodium (Na) level of 131 mEq/dL D) Platelet count of 120,000/mm3
Correct: A Metformin can reach toxic levels in individuals with renal impairment, which is indicated by a rise in the serum creatinine level. The prescriber may need to be notified of the hemoglobin, sodium, and platelet values, but they would not affect the administration of metformin.
Which instruction should the nurse provide when teaching a patient to mix regular insulin and NPH insulin in the same syringe? A) "Draw up the clear regular insulin first, followed by the cloudy NPH insulin." B) "It is not necessary to rotate the NPH insulin vial when it is mixed with regular insulin." C) "The order of drawing up insulin does not matter as long as the insulin is refrigerated." D) "Rotate subcutaneous injection sites each day among the arm, thigh, and abdomen."
Correct: A To ensure a consistent response, only NPH insulin is appropriate for mixing with a short-acting insulin. Unopened vials of insulin should be refrigerated; current vials can be kept at room temperature for up to 1 month. Drawing up the regular insulin into the syringe first prevents accidental mixture of NPH insulin into the vial of regular insulin, which could alter the pharmacokinetics of subsequent doses taken out of the regular insulin vial. NPH insulin is a cloudy solution, and it should always be rotated gently to disperse the particles evenly before loading the syringe. Subcutaneous injections should be made using one region of the body (e.g., the abdomen or thigh) and rotated within that region for 1 month.
A patient who has type 2 diabetes is taking nateglinide (Starlix). Which response should a nurse expect the patient to have if the medication is achieving the desired therapeutic effect? A) Inhibition of carbohydrate digestion B) Promotion of insulin secretion C) Decreased insulin resistance D) Inhibition of ketone formation
Correct: B Nateglinide is a meglitinide medication that acts to increase pancreatic insulin release. It is used as an adjunct to calorie restriction and exercise to maintain glycemic control in patients with type 2 diabetes. It does not act to reduce insulin resistance or inhibit carbohydrate digestion. It should not be used to manage diabetic ketone formation, because its glucose-lowering effects are too slow to be of benefit.
A nurse assesses a patient who is taking pramlintide (Symlin) with mealtime insulin. Which finding requires immediate follow-up by the nurse? A) Skin rash B) Sweating C) Itching D) Pedal edema
Correct: B Pramlintide is a new type of antidiabetic medication used as a supplement to mealtime insulin in patients with type 1 and 2 diabetes. Hypoglycemia, which is manifested by sweating, tremors, and tachycardia, is the adverse reaction of most concern. Skin rash, itching, and edema are not adverse effects of pramlintide.
A nurse caring for a patient who has diabetic ketoacidosis recognizes which characteristics in the patient? (Select all that apply.) A) Type 2 diabetes B) Altered fat metabolism leading to ketones C) Arterial blood pH of 7.35 to 7.45 D) Sudden onset, triggered by acute illness E) Plasma osmolality of 300 to 320 mOsm/L
Correct: B, D, E Diabetic ketoacidosis is the most severe manifestation of insulin deficiency in patients with type 1 diabetes. It develops and worsens acutely over several hours to days. Alterations in fat metabolism lead to the production of ketones and ketoacids. Increased ketoacid levels lead to a fall in arterial blood pH below 7.35. Altered glucose metabolism leads to hyperglycemia, water loss, and an elevated plasma osmolality (285 to 295 mOsm/L).
A patient is taking glipizide (Glucotrol) and a beta-adrenergic medication. A nurse is teaching hypoglycemia awareness and should warn the patient about the absence of which symptom? A) Vomiting B) Muscle cramps C) Tachycardia D) Chills
Correct: C Glipizide is a sulfonylurea oral hypoglycemic medication that acts to promote insulin release from the pancreas. Beta-adrenergic blockers can mask early signs of sympathetic system responses to hypoglycemia; the most important of these is tachycardia, which is the most common adverse effect of glipizide. Vomiting, muscle cramps, and chills are not symptoms of activation of the sympathetic nervous system that arise when glucose levels fall.
A patient who took NPH insulin at 0800 reports feeling weak and tremulous at 1700. Which action should the nurse take? A) Take the patient's blood pressure. B) Give the patient's PRN dose of insulin. C) Check the patient's capillary blood sugar. D) Advise the patient to lie down with the legs elevated.
Correct: C The patient is showing symptoms of hypoglycemia at 5 PM. NPH has a peak action of 8 to 10 hours after administration. Based on the duration of action of NPH insulin, the patient's hypoglycemic symptoms are from the 8 AM injection of NPH insulin. An injection of NPH insulin at 2 AM, 1 PM, or 3 PM would not cause hypoglycemic symptoms based on the average duration of action of NPH insulin. Points Earned:
A patient newly diagnosed with type 1 diabetes asks a nurse, "How does insulin normally work in my body?" The nurse explains that normal insulin has which action in the body? A) It stimulates the pancreas to reabsorb glucose. B) It promotes the synthesis of amino acids into glucose. C) It stimulates the liver to convert glycogen to glucose. D) It promotes the passage of glucose into cells for energy.
Correct: D The hormone insulin promotes the passage of glucose into cells, where it is metabolized for energy. Insulin does not stimulate the pancreas to reabsorb glucose or synthesize amino acids into glucose. It does not stimulate the liver to convert glycogen into glucose.
