Diabetes

A clinical feature that distinguishes a hypoglycemic reaction from a ketoacidosis reaction is: A. Blurred vision B. Diaphoresis C. Nausea D. Weakness

Correct answer: B. Diaphoresis A hypoglycemic reaction activates a fight-or-flight response in the body which then triggers the release of epinephrine and norepinephrine resulting in diaphoresis.

A nurse teaches a client with diabetes mellitus about foot care. Which statements should the nurse include in this clients teaching? (Select all that apply.) a. Do not walk around barefoot. b. Soak your feet in a tub each evening. c. Trim toenails straight across with a nail clipper. d. Treat any blisters or sores with Epsom salts. e. Wash your feet every other day.

ANS: A, C Clients who have diabetes mellitus are at high risk for wounds on the feet secondary to peripheral neuropathy and poor arterial circulation. The client should be instructed to not walk around barefoot or wear sandals with open toes. These actions place the client at higher risk for skin breakdown of the feet. The client should be instructed to trim toenails straight across with a nail clipper. Feet should be washed daily with lukewarm water and soap, but feet should not be soaked in the tub. The client should contact the provider immediately if blisters or sores appear and should not use home remedies to treat these wounds.

A nurse assesses clients at a health fair. Which clients should the nurse counsel to be tested for diabetes? (Select all that apply.) a. 56-year-old African-American male b. Female with a 30-pound weight gain during pregnancy c. Male with a history of pancreatic trauma d. 48-year-old woman with a sedentary lifestyle e. Male with a body mass index greater than 25 kg/m2 f. 28-year-old female who gave birth to a baby weighing 9.2 pounds

ANS: A, D, E, F Risk factors for type 2 diabetes include certain ethnic/racial groups (African Americans, American Indians, Hispanics), obesity and physical inactivity, and giving birth to large babies. Pancreatic trauma and a 30-pound gestational weight gain are not risk factors.

A nurse teaches a client with type 2 diabetes mellitus who is prescribed glipizide (Glucotrol). Which statement should the nurse include in this clients teaching? a. Change positions slowly when you get out of bed. b. Avoid taking nonsteroidal anti-inflammatory drugs (NSAIDs). c. If you miss a dose of this drug, you can double the next dose. d. Discontinue the medication if you develop a urinary infection.

ANS: B NSAIDs potentiate the hypoglycemic effects of sulfonylurea agents. Glipizide is a sulfonylurea. The other statements are not applicable to glipizide.

A client with diabetes mellitus visits a health care clinic. The client's diabetes previously had been well controlled with glyburide (Diabeta), 5 mg PO daily, but recently, the fasting blood glucose has been running 180-200 mg/dl. Which medication, if added to the clients regimen, may have contributed to the hyperglycemia? A. prednisone (Deltasone) B. atenolol (Tenormin) C. phenelzine (Nardil) D. allopurinol (Zyloprim)

Correct answer: A. prednisone (Deltasone) Prednisone may decrease the effect of oral hypoglycemics, insulin, diuretics, and potassium supplements.

A nurse provides diabetic education at a public health fair. Which disorders should the nurse include as complications of diabetes mellitus? (Select all that apply.) a. Stroke b. Kidney failure c. Blindness d. Respiratory failure e. Cirrhosis

ANS: A, B, C Complications of diabetes mellitus are caused by macrovascular and microvascular changes. Macrovascular complications include coronary artery disease, cerebrovascular disease, and peripheral vascular disease. Microvascular complications include nephropathy, retinopathy, and neuropathy. Respiratory failure and cirrhosis are not complications of diabetes mellitus.

A nurse teaches a client who is prescribed an insulin pump. Which statement should the nurse include in this clients discharge education? a. Test your urine daily for ketones. b. Use only buffered insulin in your pump. c. Store the insulin in the freezer until you need it. d. Change the needle every 3 days.

ANS: D Having the same needle remain in place through the skin for longer than 3 days drastically increases the risk for infection in or through the delivery system. Having an insulin pump does not require the client to test for ketones in the urine. Insulin should not be frozen. Insulin is not buffered.

After teaching a client with type 2 diabetes mellitus who is prescribed nateglinide (Starlix), the nurse assesses the clients understanding. Which statement made by the client indicates a correct understanding of the prescribed therapy? a. Ill take this medicine during each of my meals. b. I must take this medicine in the morning when I wake. c. I will take this medicine before I go to bed. d. I will take this medicine immediately before I eat.

ANS: D Nateglinide is an insulin secretagogue that is designed to increase meal-related insulin secretion. It should be taken immediately before each meal. The medication should not be taken without eating as it will decrease the clients blood glucose levels. The medication should be taken before meals instead of during meals.

The nurse is teaching the client newly diagnosed with type 2 DM. Which information should the nurse emphasize in the session? A. Use the arm when self-administering insulin. B. Exercise for 30 minutes daily, preferably after a meal. C. Consume 30% of the daily calorie intake from protein foods. D. Eat a 30-gram carbohydrate snack prior to strenuous activity.

ANSWER: B A. Usually type 2 DM is controlled with oral hypoglycemic agents. If insulin is needed, sites should be rotated. B. Exercise increases insulin receptor sites in the tissue and can have a direct effect on lowering blood glucose levels. Exercise contributes to weight loss, which also decreases insulin resistance. C. For those with DM, protein should contribute less than 10% of the total energy consumed. D. Strenuous activity can be perceived by the body as a stressor, causing a release of counter-regulatory hormones that subsequently increase blood glucose. Hyperglycemia can result from the combination of strenuous activity and extra carbohydrates.

A nurse reviews laboratory results for a client with diabetes mellitus who is prescribed an intensified insulin regimen: Fasting blood glucose: 75 mg/dL Postprandial blood glucose: 200 mg/dL Hemoglobin A1c level: 5.5% How should the nurse interpret these laboratory findings? a. Increased risk for developing ketoacidosis b. Good control of blood glucose c. Increased risk for developing hyperglycemia d. Signs of insulin resistance

ANS: B The client is maintaining blood glucose levels within the defined ranges for goals in an intensified regimen. Because the clients glycemic control is good, he or she is not at higher risk for ketoacidosis or hyperglycemia and is not showing signs of insulin resistance.

Rotating injection sites when administering insulin prevents which of the following complications? A. Insulin edema B. Insulin lipodystrophy C. Insulin resistance D. Systemic allergic reactions

Correct answer: B. Insulin lipodystrophy Insulin lipodystrophy produces fatty masses at the injection sites, causing unpredictable absorption of insulin injected into these sites.

A client with diabetes mellitus has an above-knee amputation because of severe peripheral vascular disease, Two days following surgery, when preparing the client for dinner, it is the nurse's primary responsibility to: A. Check the client's serum glucose level B. Assist the client out of bed to the chair C. Place the client in a High-Fowler's position D. Ensure that the client's residual limb is elevated

Correct answer: A. Check the client's serum glucose level Because the client has diabetes, it is essential that the blood glucose level is determined before meals to evaluate the success of control of diabetes and the possible need for insulin coverage.

Rotation sites for insulin injection should be separated from one another by 2.5 cm (1 inch) and should be used only every: A. Third day B. Every other day C. 1-2 weeks D. 2-4 weeks

Correct answer: C. 1-2 weeks Rotation of sites for insulin injection should be done every week or two. Frequently using the same spot over time can cause fat cells to break down or build up (lipodystrophy) causing lumps under the skin and may interfere with insulin absorption.

A client's blood gases reflect diabetic acidosis. The nurse should expect: A. Increased pH B. Decreased PO2 C. Increased PCO2 D. Decreased HCO3

Correct answer: D. Decreased HCO3 The bicarbonate-carbonic acid buffer system helps maintain the pH of the body fluids; in metabolic acidosis, there is a decrease in bicarbonate because of an increase of metabolic acids.

A client with DM demonstrates acute anxiety when first admitted for the treatment of hyperglycemia. The most appropriate intervention to decrease the client's anxiety would be to: A. Administer a sedative B. Make sure the client knows all the correct medical terms to understand what is happening C. Ignore the signs and symptoms of anxiety so that they will soon disappear D. Convey empathy, trust, and respect toward the client

Correct answer: D. Convey empathy, trust, and respect toward the client. Option D: The most appropriate intervention is to address the client's feelings related to anxiety. Option A: Administering a sedative is not the most appropriate intervention. Option B: A client will not relate to medical terms, particularly when anxiety exists. Option C: The nurse should not ignore the client's anxious feelings.

Knowing that gluconeogenesis helps to maintain blood glucose levels, a nurse should: A. Document weight changes because of fatty acid mobilization. B. Evaluate the patient's sensitivity to low room temperatures because of decreased adipose tissue insulation. C. Protect the patient from sources of infection because of decreased cellular protein deposits. D. Do all of the above.

Correct answer: D. Do all of the above All measures ensure gluconeogenesis in maintaining glucose homeostasis.

A nurse performs a physical assessment on a client with type 2 diabetes mellitus. Findings include fasting blood glucose of 120mg/dl, temperature of 101ºF, pulse of 88 bpm, respirations of 22 bpm, and a BP of 140/84 mmHg. Which finding would be of most concern to the nurse? A. Pulse B. Blood pressure C. Respiration D. Temperature

Correct answer: D. Temperature An elevated temperature may indicate infection. Infection is a leading cause of hyperglycemic hyperosmolar nonketotic syndrome or diabetic ketoacidosis.

A 44-year-old woman with type 1 diabetes comes to the emergency department due to abdominal pain accompanied by nausea and vomiting. The patient had a history of chronic back pain due to a motor accident 20 years ago. Her situation renders her unable to work and pay for the increasing price of insulin, which has doubled during the last five years. The patient doesn't have medical coverage or insurance; therefore, she rations her insulin intake, making her unable to follow her prescribed therapeutic regimen for her diabetes. Because of her situation, the client is at high risk of developing diabetic ketoacidosis. As her nurse, which of the following symptoms would you anticipate the client to exhibit? Select all that apply. A. Fruity odor breath B. Deep and labored respirations C. Blurred vision D. Increased urination E. Increased thirst F. Fatigue G. Blood glucose level of 60 mg/dL H. Dehydration I. Respiratory rate of 8 bpm J. Hypernatremia K. Metabolic alkalosis

Correct answers: A, B, C, D, E, F, and H. Option A: Fruity odor breath or acetone breath occurs with elevated ketone levels. Insulin deficiency causes lipolysis into free fatty acids and glycerol. These free fatty acids are converted into ketones by the liver. Option B: Deep and labored respiration is another indication of high ketones in the body. This type of respiration (Kussmaul breathing) is an attempt of the respiratory system to decrease acidosis and counteracting the effects of ketone built up. Option C: Blurred vision occurs when an increase in blood glucose levels causes changes in retinal blood vessels causing them to swell up. Options D: Increased urination or polyuria is an attempt of the body to excrete excess glucose produced by the liver (gluconeogenesis). Option E: Increased thirst (polydipsia) occurs due to increased urination. Option F: DKA causes alterations in blood glucose levels which may result in fatigue. Altered blood glucose metabolism may result in acute and chronic hyperglycemic episodes, hypoglycemia, or blood glucose fluctuations. Option G: DKA is caused by a deficiency in insulin. Without insulin, the amount of glucose entering the cells is reduced causing hyperglycemia and not hypoglycemia. Option H: Excess glucose in the body causes the kidneys to excrete glucose along with water and electrolytes. This causes excessive urination leading to dehydration. Patients with DKA can lose up to 7 liters of water over a 24 hour period. Option I: DKA is characterized by hyperventilation and not hypoventilation due to the body's attempt to decrease acidosis caused by ketone buildup. Option J: Due to an increase in urination, there is hyponatremia in DKA rather than hypernatremia. Patients with DKA can lose 500 mEq of sodium, potassium, and chloride. Option K: Metabolic acidosis occurs in DKA due to ketone bodies which are acids. Their accumulation leads to metabolic acidosis and not metabolic alkalosis.

The nurse recognizes that additional teaching is necessary when the client who is learning alternative site testing (AST) for glucose monitoring says: A. "I need to rub my forearm vigorously until warm before testing at this site." B. "The fingertip is preferred for glucose monitoring if hyperglycemia is suspected." C. "I have to make sure that my current glucose monitor can be used at an alternate site." D. "Alternate site testing is unsafe if I am experiencing a rapid change in glucose levels."

Correct answer: B. "The fingertip is preferred for glucose monitoring if hyperglycemia is suspected." The fingertip is preferred for glucose monitoring if hypoglycemia, not hyperglycemia, is suspected.

The nurse expects that a type 1 diabetic may receive how much of his or her morning dose of insulin preoperatively? A. 10-20% B. 25-40% C. 50-60% D. 85-90%

Correct answer: C. 50-60% Surgical procedures may result in a number of metabolic perturbations that can alter normal glucose homeostasis. Patients with type 1 diabetes mellitus who are using long-acting insulins, such as glargine, should continue these as normal when fasting. If the patient is prone to morning hypoglycemia, the dose can be reduced by 20%. Thus, the diabetic patient may receive 80% of his or her morning dose of insulin preoperatively. Patients taking premixed insulins or fixed-combination insulins are more of a challenge. It may not be feasible or economical to change the patient's premixed insulin just before surgery. In these situations, the patient can take ½ - ¾ of the morning dose, followed by administration of a dextrose-containing intravenous fluid and frequent blood glucose checks.

When a client is first admitted with hyperglycemic hyperosmolar nonketotic syndrome (HHNS), the nurse's priority is to provide: A. Oxygen B. Carbohydrates C. Fluid replacement D. Dietary instruction

Correct answer: C. Fluid replacement As a result of osmotic pressures created by increased serum glucose, the cells become dehydrated; the client must receive fluid and then insulin.

The nurse knows that glucagon may be given in the treatment of hypoglycemia because it: A. Inhibits gluconeogenesis B. Stimulates the release of insulin C. Increases blood glucose levels D. Provides more storage of glucose.

Correct answer: C. Increases blood glucose levels Glucagon, an insulin antagonist produced by the alpha cells in the islets of Langerhans, leads to the conversion of glycogen to glucose in the liver.

Which of the following nursing interventions should be taken for a client who complains of nausea and vomits one hour after taking his glyburide (DiaBeta)? A. Give glyburide again B. Give subcutaneous insulin and monitor blood glucose C. Monitor blood glucose closely, and look for signs of hypoglycemia D. Monitor blood glucose, and assess for signs of hyperglycemia

Correct answer: C. Monitor blood glucose closely, and look for signs of hypoglycemia. Option C: When a client who has taken an oral antidiabetic agent vomits, the nurse would monitor glucose and assess him frequently for signs of hypoglycemia. Option A: Most of the medication has probably been absorbed. Therefore, repeating the dose would further lower glucose levels later in the day. Option B: Giving insulin would also lower the glucose levels, causing hypoglycemic. Option D: The client wouldn't have hyperglycemia if the glyburide was absorbed.

The nurse is admitting a client with hypoglycemia. Identify the signs and symptoms the nurse should expect. Select all that apply. A. Thirst B. Palpitations C. Diaphoresis D. Slurred speech E. Hyperventilation

Correct answers: B. Palpitations, C. Diaphoresis, and D. Slurred speech Palpitations, an adrenergic symptom, occur as the glucose levels fall; the sympathetic nervous system is activated and epinephrine and norepinephrine are secreted causing this response. Diaphoresis is a sympathetic nervous system response that occurs as epinephrine and norepinephrine are released. Slurred speech is a neuroglycopenic symptom; as the brain receives insufficient glucose, the activity of the CNS becomes depressed.

A client with type 1 diabetes mellitus calls the nurse to report recurrent episodes of hypoglycemia with exercise. Which statement by the client indicated an inadequate understanding of the peak action of NPH insulin and exercise? A. "The best time for me to exercise is every afternoon." B. "The best time for me to exercise is right after I eat." C. "The best time for me to exercise is after breakfast." D. "The best time for me to exercise is after my morning snack."

Correct answer: A. "The best time for me to exercise is every afternoon." Option A: A hypoglycemic reaction may occur in response to increased exercise. Clients should avoid exercise during the peak time of insulin. NPH insulin peaks at 6-14 hours; therefore afternoon exercise will occur during the peak of the medication. Options B, C, and D do not address peak action times.

A nurse collaborates with the interdisciplinary team to develop a plan of care for a client who is newly diagnosed with diabetes mellitus. Which team members should the nurse include in this interdisciplinary team meeting? (Select all that apply.) a. Registered dietitian b. Clinical pharmacist c. Occupational therapist d. Health care provider e. Speech-language pathologist

ANS: A, B, D When planning care for a client newly diagnosed with diabetes mellitus, the nurse should collaborate with a registered dietitian, clinical pharmacist, and health care provider. The focus of treatment for a newly diagnosed client would be nutrition, medication therapy, and education. The nurse could also consult with a diabetic educator. There is no need for occupational therapy or speech therapy at this time.

A nurse assesses a client who is experiencing diabetic ketoacidosis (DKA). For which manifestations should the nurse monitor the client? (Select all that apply.) a. Deep and fast respirations b. Decreased urine output c. Tachycardia d. Dependent pulmonary crackles e. Orthostatic hypotension

ANS: A, C, E DKA leads to dehydration, which is manifested by tachycardia and orthostatic hypotension. Usually clients have Kussmaul respirations, which are fast and deep. Increased urinary output (polyuria) is severe. Because of diuresis and dehydration, peripheral edema and crackles do not occur.

A nurse teaches a client with type 1 diabetes mellitus. Which statement should the nurse include in this clients teaching to decrease the clients insulin needs? a. Limit your fluid intake to 2 liters a day. b. Animal organ meat is high in insulin. c. Limit your carbohydrate intake to 80 grams a day. d. Walk at a moderate pace for 1 mile daily.

ANS: D Moderate exercise such as walking helps regulate blood glucose levels on a daily basis and results in lowered insulin requirements for clients with type 1 diabetes mellitus. Restricting fluids and eating organ meats will not reduce insulin needs. People with diabetes need at least 130 grams of carbohydrates each day.

After teaching a client who is recovering from pancreas transplantation, the nurse assesses the clients understanding. Which statement made by the client indicates a need for additional education? a. If I develop an infection, I should stop taking my corticosteroid. b. If I have pain over the transplant site, I will call the surgeon immediately. c. I should avoid people who are ill or who have an infection. d. I should take my cyclosporine exactly the way I was taught.

ANS: A Immunosuppressive agents should not be stopped without the consultation of the transplantation physician, even if an infection is present. Stopping immunosuppressive therapy endangers the transplanted organ. The other statements are correct. Pain over the graft site may indicate rejection. Anti-rejection drugs cause immunosuppression, and the client should avoid crowds and people who are ill. Changing the routine of anti- rejection medications may cause them to not work optimally.

A preoperative nurse assesses a client who has type 1 diabetes mellitus prior to a surgical procedure. The clients blood glucose level is 160 mg/dL. Which action should the nurse take? a. Document the finding in the clients chart. b. Administer a bolus of regular insulin IV. c. Call the surgeon to cancel the procedure. d. Draw blood gases to assess the metabolic state.

ANS: A Clients who have type 1 diabetes and are having surgery have been found to have fewer complications, lower rates of infection, and better wound healing if blood glucose levels are maintained at between 140 and 180 mg/dL throughout the perioperative period. The nurse should document the finding and proceed with other operative care. The need for a bolus of insulin, canceling the procedure, or drawing arterial blood gases is not required.

A nurse teaches a client who is diagnosed with diabetes mellitus. Which statement should the nurse include in this clients plan of care to delay the onset of microvascular and macrovascular complications? a. Maintain tight glycemic control and prevent hyperglycemia. b. Restrict your fluid intake to no more than 2 liters a day. c. Prevent hypoglycemia by eating a bedtime snack. d. Limit your intake of protein to prevent ketoacidosis.

ANS: A Hyperglycemia is a critical factor in the pathogenesis of long-term diabetic complications. Maintaining tight glycemic control will help delay the onset of complications. Restricting fluid intake is not part of the treatment plan for clients with diabetes. Preventing hypoglycemia and ketosis, although important, are not as important as maintaining daily glycemic control.

A nurse teaches a client about self-monitoring of blood glucose levels. Which statement should the nurse include in this clients teaching to prevent bloodborne infections? a. Wash your hands after completing each test. b. Do not share your monitoring equipment. c. Blot excess blood from the strip with a cotton ball. d. Use gloves when monitoring your blood glucose.

ANS: B Small particles of blood can adhere to the monitoring device, and infection can be transported from one user to another. Hepatitis B in particular can survive in a dried state for about a week. The client should be taught to avoid sharing any equipment, including the lancet holder. The client should be taught to wash his or her hands before testing. The client would not need to blot excess blood away from the strip or wear gloves.

A nurse prepares to administer insulin to a client at 1800. The clients medication administration record contains the following information: Insulin glargine: 12 units daily at 1800 Regular insulin: 6 units QID at 0600, 1200, 1800, 2400 Based on the clients medication administration record, which action should the nurse take? a. Draw up and inject the insulin glargine first, and then draw up and inject the regular insulin. b. Draw up and inject the insulin glargine first, wait 20 minutes, and then draw up and inject the regular insulin. c. First draw up the dose of regular insulin, then draw up the dose of insulin glargine in the same syringe, mix, and inject the two insulins together. d. First draw up the dose of insulin glargine, then draw up the dose of regular insulin in the same syringe, mix, and inject the two insulins together.

ANS: A Insulin glargine must not be diluted or mixed with any other insulin or solution. Mixing results in an unpredictable alteration in the onset of action and time to peak action. The correct instruction is to draw up and inject first the glargine and then the regular insulin right afterward.

A nurse cares for a client with diabetes mellitus who is visually impaired. The client asks, Can I ask my niece to prefill my syringes and then store them for later use when I need them? How should the nurse respond? a. Yes. Prefilled syringes can be stored for 3 weeks in the refrigerator in a vertical position with the needle pointing up. b. Yes. Syringes can be filled with insulin and stored for a month in a location that is protected from light. c. Insulin reacts with plastic, so prefilled syringes are okay, but you will need to use glass syringes. d. No. Insulin syringes cannot be prefilled and stored for any length of time outside of the container.

ANS: A Insulin is relatively stable when stored in a cool, dry place away from light. When refrigerated, prefilled plastic syringes are stable for up to 3 weeks. They should be stored in the refrigerator in the vertical position with the needle pointing up to prevent suspended insulin particles from clogging the needle.

An emergency department nurse assesses a client with ketoacidosis. Which clinical manifestation should the nurse correlate with this condition? a. Increased rate and depth of respiration b. Extremity tremors followed by seizure activity c. Oral temperature of 102 F (38.9 C) d. Severe orthostatic hypotension

ANS: A Ketoacidosis decreases the pH of the blood, stimulating the respiratory control areas of the brain to buffer the effects of increasing acidosis. The rate and depth of respiration are increased (Kussmaul respirations) in an attempt to excrete more acids by exhalation. Tremors, elevated temperature, and orthostatic hypotension are not associated with ketoacidosis.

A nurse cares for a client who has a family history of diabetes mellitus. The client states, My father has type 1 diabetes mellitus. Will I develop this disease as well? How should the nurse respond? a. Your risk of diabetes is higher than the general population, but it may not occur. b. No genetic risk is associated with the development of type 1 diabetes mellitus. c. The risk for becoming a diabetic is 50% because of how it is inherited. d. Female children do not inherit diabetes mellitus, but male children will.

ANS: A Risk for type 1 diabetes is determined by inheritance of genes coding for HLA-DR and HLA-DQ tissue types. Clients who have one parent with type 1 diabetes are at increased risk for its development. Diabetes (type 1) seems to require interaction between inherited risk and environmental factors, so not everyone with these genes develops diabetes. The other statements are not accurate.

After teaching a client with diabetes mellitus to inject insulin, the nurse assesses the clients understanding. Which statement made by the client indicates a need for additional teaching? a. The lower abdomen is the best location because it is closest to the pancreas. b. I can reach my thigh the best, so I will use the different areas of my thighs. c. By rotating the sites in one area, my chance of having a reaction is decreased. d. Changing injection sites from the thigh to the arm will change absorption rates.

ANS: A The abdominal site has the fastest rate of absorption because of blood vessels in the area, not because of its proximity to the pancreas. The other statements are accurate assessments of insulin administration.

A nurse assesses a client with diabetes mellitus and notes the client only responds to a sternal rub by moaning, has capillary blood glucose of 33 g/dL, and has an intravenous line that is infiltrated with 0.45% normal saline. Which action should the nurse take first? a. Administer 1 mg of intramuscular glucagon. b. Encourage the client to drink orange juice. c. Insert a new intravenous access line. d. Administer 25 mL dextrose 50% (D50) IV push.

ANS: A The clients blood glucose level is dangerously low. The nurse needs to administer glucagon IM immediately to increase the clients blood glucose level. The nurse should insert a new IV after administering the glucagon and can use the new IV site for future doses of D50 if the clients blood glucose level does not rise. Once the client is awake, orange juice may be administered orally along with a form of protein such as a peanut butter.

A nurse assesses a client who has diabetes mellitus and notes the client is awake and alert, but shaky, diaphoretic, and weak. Five minutes after administering a half-cup of orange juice, the clients clinical manifestations have not changed. Which action should the nurse take next? a. Administer another half-cup of orange juice. b. Administer a half-ampule of dextrose 50% intravenously. c. Administer 10 units of regular insulin subcutaneously. d. Administer 1 mg of glucagon intramuscularly.

ANS: A This client is experiencing mild hypoglycemia. For mild hypoglycemic manifestations, the nurse should administer oral glucose in the form of orange juice. If the symptoms do not resolve immediately, the treatment should be repeated. The client does not need intravenous dextrose, insulin, or glucagon.

A nurse prepares to administer prescribed regular and NPH insulin. Place the nurses actions in the correct order to administer these medications. 1. Inspect bottles for expiration dates. 2. Gently roll the bottle of NPH between the hands. 3. Wash your hands. 4. Inject air into the regular insulin. 5. Withdraw the NPH insulin. 6. Withdraw the regular insulin. 7. Inject air into the NPH bottle. 8. Clean rubber stoppers with an alcohol swab. a. 1, 3, 8, 2, 4, 6, 7, 5 b. 3, 1, 2, 8, 7, 4, 6, 5 c. 8, 1, 3, 2, 4, 6, 7, 5 d. 2, 3, 1, 8, 7, 5, 4, 6

ANS: B After washing hands, it is important to inspect the bottles and then to roll the NPH to mix the insulin. Rubber stoppers should be cleaned with alcohol after rolling the NPH and before sticking a needle into either bottle. It is important to inject air into the NPH bottle before placing the needle in a regular insulin bottle to avoid mixing of regular and NPH insulin. The shorter-acting insulin is always drawn up first.

A nurse cares for a client who is diagnosed with acute rejection 2 months after receiving a simultaneous pancreas-kidney transplant. The client states, I was doing so well with my new organs, and the thought of having to go back to living on hemodialysis and taking insulin is so depressing. How should the nurse respond? a. Following the drug regimen more closely would have prevented this. b. One acute rejection episode does not mean that you will lose the new organs. c. Dialysis is a viable treatment option for you and may save your life. d. Since you are on the national registry, you can receive a second transplantation.

ANS: B An episode of acute rejection does not automatically mean that the client will lose the transplant. Pharmacologic manipulation of host immune responses at this time can limit damage to the organ and allow the graft to be maintained. The other statements either belittle the client or downplay his or her concerns. The client may not be a candidate for additional organ transplantation.

A nurse is teaching a client with diabetes mellitus who asks, Why is it necessary to maintain my blood glucose levels no lower than about 60 mg/dL? How should the nurse respond? a. Glucose is the only fuel used by the body to produce the energy that it needs. b. Your brain needs a constant supply of glucose because it cannot store it. c. Without a minimum level of glucose, your body does not make red blood cells. d. Glucose in the blood prevents the formation of lactic acid and prevents acidosis.

ANS: B Because the brain cannot synthesize or store significant amounts of glucose, a continuous supply from the bodys circulation is needed to meet the fuel demands of the central nervous system. The nurse would want to educate the client to prevent hypoglycemia. The body can use other sources of fuel, including fat and protein, and glucose is not involved in the production of red blood cells. Glucose in the blood will encourage glucose metabolism but is not directly responsible for lactic acid formation.

After teaching a client with type 2 diabetes mellitus, the nurse assesses the clients understanding. Which statement made by the client indicates a need for additional teaching? a. I need to have an annual appointment even if my glucose levels are in good control. b. Since my diabetes is controlled with diet and exercise, I must be seen only if I am sick. c. I can still develop complications even though I do not have to take insulin at this time. d. If I have surgery or get very ill, I may have to receive insulin injections for a short time.

ANS: B Clients with diabetes need to be seen at least annually to monitor for long-term complications, including visual changes, microalbuminuria, and lipid analysis. The client may develop complications and may need insulin in the future.

A nurse reviews the medication list of a client with a 20-year history of diabetes mellitus. The client holds up the bottle of prescribed duloxetine (Cymbalta) and states, My cousin has depression and is taking this drug. Do you think Im depressed? How should the nurse respond? a. Many people with long-term diabetes become depressed after a while. b. Its for peripheral neuropathy. Do you have burning pain in your feet or hands? c. This antidepressant also has anti-inflammatory properties for diabetic pain. d. No. Many medications can be used for several different disorders.

ANS: B Damage along nerves causes peripheral neuropathy and leads to burning pain along the nerves. Many drugs, including duloxetine (Cymbalta), can be used to treat peripheral neuropathy. The nurse should assess the client for this condition and then should provide an explanation of why this drug is being used. This medication, although it is used for depression, is not being used for that reason in this case. Duloxetine does not have anti- inflammatory properties. Telling the client that many medications are used for different disorders does not provide the client with enough information to be useful.

A nurse cares for a client with diabetes mellitus who asks, Why do I need to administer more than one injection of insulin each day? How should the nurse respond? a. You need to start with multiple injections until you become more proficient at self-injection. b. A single dose of insulin each day would not match your blood insulin levels and your food intake patterns. c. A regimen of a single dose of insulin injected each day would require that you eat fewer carbohydrates. d. A single dose of insulin would be too large to be absorbed, predictably putting you at risk for insulin shock.

ANS: B Even when a single injection of insulin contains a combined dose of different-acting insulin types, the timing of the actions and the timing of food intake may not match well enough to prevent wide variations in blood glucose levels. One dose of insulin would not be appropriate even if the client decreased carbohydrate intake. Additional injections are not required to allow the client practice with injections, nor will one dose increase the clients risk of insulin shock.

A nurse cares for a client who has diabetes mellitus. The nurse administers 6 units of regular insulin and 10 units of NPH insulin at 0700. At which time should the nurse assess the client for potential problems related to the NPH insulin? a. 0800 b. 1600 c. 2000 d. 2300

ANS: B Neutral protamine Hagedorn (NPH) is an intermediate-acting insulin with an onset of 1.5 hours, peak of 4 to 12 hours, and duration of action of 22 hours. Checking the client at 0800 would be too soon. Checking the client at 2000 and 2300 would be too late. The nurse should check the client at 1600.

A nurse assesses a client with diabetes mellitus. Which clinical manifestation should alert the nurse to decreased kidney function in this client? a. Urine specific gravity of 1.033 b. Presence of protein in the urine c. Elevated capillary blood glucose level d. Presence of ketone bodies in the urine

ANS: B Renal dysfunction often occurs in the client with diabetes. Proteinuria is a result of renal dysfunction. Specific gravity is elevated with dehydration. Elevated capillary blood glucose levels and ketones in the urine are consistent with diabetes mellitus but are not specific to renal function.

A nurse develops a dietary plan for a client with diabetes mellitus and new-onset microalbuminuria. Which component of the clients diet should the nurse decrease? a. Carbohydrates b. Proteins c. Fats d. Total calories

ANS: B Restriction of dietary protein to 0.8 g/kg of body weight per day is recommended for clients with microalbuminuria to delay progression to renal failure. The clients diet does not need to be decreased in carbohydrates, fats, or total calories.

A nurse reviews the chart and new prescriptions for a client with diabetic ketoacidosis: Vital Signs and Assessment: Blood pressure: 90/62 mm Hg Pulse: 120 beats/min Respiratory rate: 28 breaths/min Urine output: 20 mL/hr via catheter Laboratory Results: Serum potassium: 2.6 mEq/L Medications: Potassium chloride 40 mEq IV bolus STAT Increase IV fluid to 100 mL/hr Which action should the nurse take? a. Administer the potassium and then consult with the provider about the fluid order. b. Increase the intravenous rate and then consult with the provider about the potassium prescription. c. Administer the potassium first before increasing the infusion flow rate. d. Increase the intravenous flow rate before administering the potassium.

ANS: B The client is acutely ill and is severely dehydrated and hypokalemic. The client requires more IV fluids and potassium. However, potassium should not be infused unless the urine output is at least 30 mL/hr. The nurse should first increase the IV rate and then consult with the provider about the potassium.

A nurse cares for a client who is prescribed pioglitazone (Actos). After 6 months of therapy, the client reports that his urine has become darker since starting the medication. Which action should the nurse take? a. Assess for pain or burning with urination. b. Review the clients liver function study results. c. Instruct the client to increase water intake. d. Test a sample of urine for occult blood.

ANS: B Thiazolidinediones (including pioglitazone) can affect liver function; liver function should be assessed at the start of therapy and at regular intervals while the client continues to take these drugs. Dark urine is one indicator of liver impairment because bilirubin is increased in the blood and is excreted in the urine. The nurse should check the clients most recent liver function studies. The nurse does not need to assess for pain or burning with urination and does not need to check the urine for occult blood. The client does not need to be told to increase water intake.

A nurse teaches a client with diabetes mellitus about sick day management. Which statement should the nurse include in this clients teaching? a. When ill, avoid eating or drinking to reduce vomiting and diarrhea. b. Monitor your blood glucose levels at least every 4 hours while sick. c. If vomiting, do not use insulin or take your oral antidiabetic agent. d. Try to continue your prescribed exercise regimen even if you are sick.

ANS: B When ill, the client should monitor his or her blood glucose at least every 4 hours. The client should continue taking the medication regimen while ill. The client should continue to eat and drink as tolerated but should not exercise while sick.

A nurse assesses a client who has diabetes mellitus. Which arterial blood gas values should the nurse identify as potential ketoacidosis in this client? a. pH 7.38, HCO3 22 mEq/L, PCO2 38 mm Hg, PO2 98 mm Hg b. pH 7.28, HCO3 18 mEq/L, PCO2 28 mm Hg, PO2 98 mm Hg c. pH 7.48, HCO3 28 mEq/L, PCO2 38 mm Hg, PO2 98 mm Hg d. pH 7.32, HCO3 22 mEq/L, PCO2 58 mm Hg, PO2 88 mm Hg

ANS: B When the lungs can no longer offset acidosis, the pH decreases to below normal. A client who has diabetic ketoacidosis would present with arterial blood gas values that show primary metabolic acidosis with decreased bicarbonate levels and a compensatory respiratory alkalosis with decreased carbon dioxide levels.

A nurse assesses a client who is being treated for hyperglycemic-hyperosmolar state (HHS). Which clinical manifestation indicates to the nurse that the therapy needs to be adjusted? a. Serum potassium level has increased. b. Blood osmolarity has decreased. c. Glasgow Coma Scale score is unchanged. d. Urine remains negative for ketone bodies.

ANS: C A slow but steady improvement in central nervous system functioning is the best indicator of therapy effectiveness for HHS. Lack of improvement in the level of consciousness may indicate inadequate rates of fluid replacement. The Glasgow Coma Scale assesses the clients state of consciousness against criteria of a scale including best eye, verbal, and motor responses. An increase in serum potassium, decreased blood osmolality, and urine negative for ketone bodies do not indicate adequacy of treatment.

A nurse assesses a client who has a 15-year history of diabetes and notes decreased tactile sensation in both feet. Which action should the nurse take first? a. Document the finding in the clients chart. b. Assess tactile sensation in the clients hands. c. Examine the clients feet for signs of injury. d. Notify the health care provider.

ANS: C Diabetic neuropathy is common when the disease is of long duration. The client is at great risk for injury in any area with decreased sensation because he or she is less able to feel injurious events. Feet are common locations for neuropathy and injury, so the nurse should inspect them for any signs of injury. After assessment, the nurse should document findings in the clients chart. Testing sensory perception in the hands may or may not be needed. The health care provider can be notified after assessment and documentation have been completed.

After teaching a client who is newly diagnosed with type 2 diabetes mellitus, the nurse assesses the clients understanding. Which statement made by the client indicates a need for additional teaching? a. I should increase my intake of vegetables with higher amounts of dietary fiber. b. My intake of saturated fats should be no more than 10% of my total calorie intake. c. I should decrease my intake of protein and eliminate carbohydrates from my diet. d. My intake of water is not restricted by my treatment plan or medication regimen.

ANS: C The client should not completely eliminate carbohydrates from the diet, and should reduce protein if microalbuminuria is present. The client should increase dietary intake of complex carbohydrates, including vegetables, and decrease intake of fat. Water does not need to be restricted unless kidney failure is present.

At 4:45 p.m., a nurse assesses a client with diabetes mellitus who is recovering from an abdominal hysterectomy 2 days ago. The nurse notes that the client is confused and diaphoretic. The nurse reviews the assessment data provided in the chart below: Capillary Blood Glucose Testing (AC/HS): At 0630: 95 At 1130: 70 At 1630: 47 Dietary Intake: Breakfast: 10% eaten client states she is not hungry Lunch: 5% eaten client is nauseous; vomits once After reviewing the clients assessment data, which action is appropriate at this time? a. Assess the clients oxygen saturation level and administer oxygen. b. Reorient the client and apply a cool washcloth to the clients forehead. c. Administer dextrose 50% intravenously and reassess the client. d. Provide a glass of orange juice and encourage the client to eat dinner.

ANS: C The clients symptoms are related to hypoglycemia. Since the client has not been tolerating food, the nurse should administer dextrose intravenously. The clients oxygen level could be checked, but based on the information provided, this is not the priority. The client will not be reoriented until the glucose level rises.

A nurse assesses a client with diabetes mellitus 3 hours after a surgical procedure and notes the clients breath has a fruity odor. Which action should the nurse take? a. Encourage the client to use an incentive spirometer. b. Increase the clients intravenous fluid flow rate. c. Consult the provider to test for ketoacidosis. d. Perform meticulous pulmonary hygiene care.

ANS: C The stress of surgery increases the action of counterregulatory hormones and suppresses the action of insulin, predisposing the client to ketoacidosis and metabolic acidosis. One manifestation of ketoacidosis is a fruity odor to the breath. Documentation should occur after all assessments have been completed. Using an incentive spirometer, increasing IV fluids, and performing pulmonary hygiene will not address this clients problem.

A nurse teaches a client with diabetes mellitus who is experiencing numbness and reduced sensation. Which statement should the nurse include in this clients teaching to prevent injury? a. Examine your feet using a mirror every day. b. Rotate your insulin injection sites every week. c. Check your blood glucose level before each meal. d. Use a bath thermometer to test the water temperature.

ANS: D Clients with diminished sensory perception can easily experience a burn injury when bathwater is too hot. Instead of checking the temperature of the water by feeling it, they should use a thermometer. Examining the feet daily does not prevent injury, although daily foot examinations are important to find problems so they can be addressed. Rotating insulin and checking blood glucose levels will not prevent injury.

When teaching a client recently diagnosed with type 1 diabetes mellitus, the client states, I will never be able to stick myself with a needle. How should the nurse respond? a. I can give your injections to you while you are here in the hospital. b. Everyone gets used to giving themselves injections. It really does not hurt. c. Your disease will not be managed properly if you refuse to administer the shots. d. Tell me what it is about the injections that are concerning you.

ANS: D Devote as much teaching time as possible to insulin injection and blood glucose monitoring. Clients with newly diagnosed diabetes are often fearful of giving themselves injections. If the client is worried about giving the injections, it is best to try to find out what specifically is causing the concern, so it can be addressed. Giving the injections for the client does not promote self-care ability. Telling the client that others give themselves injections may cause the client to feel bad. Stating that you dont know another way to manage the disease is dismissive of the clients concerns.

A nurse assesses clients who are at risk for diabetes mellitus. Which client is at greatest risk? a. A 29-year-old Caucasian b. A 32-year-old African- American c. A 44-year-old Asian d. A 48-year-old American Indian

ANS: D Diabetes is a particular problem among African Americans, Hispanics, and American Indians. The incidence of diabetes increases in all races and ethnic groups with age. Being both an American Indian and middle-aged places this client at highest risk.

After teaching a young adult client who is newly diagnosed with type 1 diabetes mellitus, the nurse assesses the clients understanding. Which statement made by the client indicates a correct understanding of the need for eye examinations? a. At my age, I should continue seeing the ophthalmologist as I usually do. b. I will see the eye doctor when I have a vision problem and yearly after age 40. c. My vision will change quickly. I should see the ophthalmologist twice a year. d. Diabetes can cause blindness, so I should see the ophthalmologist yearly.

ANS: D Diabetic retinopathy is a leading cause of blindness in North America. All clients with diabetes, regardless of age, should be examined by an ophthalmologist (rather than an optometrist or optician) at diagnosis and at least yearly thereafter.

After teaching a client who has diabetes mellitus and proliferative retinopathy, nephropathy, and peripheral neuropathy, the nurse assesses the clients understanding. Which statement made by the client indicates a correct understanding of the teaching? a. I have so many complications; exercising is not recommended. b. I will exercise more frequently because I have so many complications. c. I used to run for exercise; I will start training for a marathon. d. I should look into swimming or water aerobics to get my exercise.

ANS: D Exercise is not contraindicated for this client, although modifications based on existing pathology are necessary to prevent further injury. Swimming or water aerobics will give the client exercise without the worry of having the correct shoes or developing a foot injury. The client should not exercise too vigorously.

A nurse reviews the medication list of a client recovering from a computed tomography (CT) scan with IV contrast to rule out small bowel obstruction. Which medication should alert the nurse to contact the provider and withhold the prescribed dose? a. Pioglitazone (Actos) b. Glimepiride (Amaryl) c. Glipizide (Glucotrol) d. Metformin (Glucophage)

ANS: D Glucophage should not be administered when the kidneys are attempting to excrete IV contrast from the body. This combination would place the client at high risk for kidney failure. The nurse should hold the metformin dose and contact the provider. The other medications are safe to administer after receiving IV contrast.

A nurse reviews laboratory results for a client with diabetes mellitus who presents with polyuria, lethargy, and a blood glucose of 560 mg/dL. Which laboratory result should the nurse correlate with the clients polyuria? a. Serum sodium: 163 mEq/L b. Serum creatinine: 1.6 mg/dL c. Presence of urine ketone bodies d. Serum osmolarity: 375 mOsm/kg

ANS: D Hyperglycemia causes hyperosmolarity of extracellular fluid. This leads to polyuria from an osmotic diuresis. The clients serum osmolarity is high. The clients sodium would be expected to be high owing to dehydration. Serum creatinine and urine ketone bodies are not related to the polyuria.

A nurse reviews the laboratory results of a client who is receiving intravenous insulin. Which should alert the nurse to intervene immediately? a. Serum chloride level of 98 mmol/L b. Serum calcium level of 8.8 mg/dL c. Serum sodium level of 132 mmol/L d. Serum potassium level of 2.5 mmol/L

ANS: D Insulin activates the sodium-potassium ATPase pump, increasing the movement of potassium from the extracellular fluid into the intracellular fluid, resulting in hypokalemia. In hyperglycemia, hypokalemia can also result from excessive urine loss of potassium. The chloride level is normal. The calcium and sodium levels are slightly low, but this would not be related to hyperglycemia and insulin administration.

A nurse assesses a client with diabetes mellitus who self-administers subcutaneous insulin. The nurse notes a spongy, swelling area at the site the client uses most frequently for insulin injection. Which action should the nurse take? a. Apply ice to the site to reduce inflammation. b. Consult the provider for a new administration route. c. Assess the client for other signs of cellulitis. d. Instruct the client to rotate sites for insulin injection.

ANS: D The clients tissue has been damaged from continuous use of the same site. The client should be educated to rotate sites. The damaged tissue is not caused by cellulitis or any type infection, and applying ice may cause more damage to the tissue. Insulin can only be administered subcutaneously and intravenously. It would not be appropriate or practical to change the administration route.

A nurse cares for a client experiencing diabetic ketoacidosis who presents with Kussmaul respirations. Which action should the nurse take? a. Administration of oxygen via face mask b. Intravenous administration of 10% glucose c. Implementation of seizure precautions d. Administration of intravenous insulin

ANS: D The rapid, deep respiratory efforts of Kussmaul respirations are the bodys attempt to reduce the acids produced by using fat rather than glucose for fuel. Only the administration of insulin will reduce this type of respiration by assisting glucose to move into cells and to be used for fuel instead of fat. The client who is in ketoacidosis may not experience any respiratory impairment and therefore does not need additional oxygen. Giving the client glucose would be contraindicated. The client does not require seizure precautions.

A nurse cares for a client who has type 1 diabetes mellitus. The client asks, Is it okay for me to have an occasional glass of wine? How should the nurse respond? a. Drinking any wine or alcohol will increase your insulin requirements. b. Because of poor kidney function, people with diabetes should avoid alcohol. c. You should not drink alcohol because it will make you hungry and overeat. d. One glass of wine is okay with a meal and is counted as two fat exchanges.

ANS: D Under normal circumstances, blood glucose levels will not be affected by moderate use of alcohol when diabetes is well controlled. Because alcohol can induce hypoglycemia, it should be ingested with or shortly after a meal. One alcoholic beverage is substituted for two fat exchanges when caloric intake is calculated. Kidney function is not impacted by alcohol intake. Alcohol is not associated with increased hunger or overeating.

The clinic nurse is evaluating the client with type 1 DM who intends to enroll in a tennis class. Which statement made by the client indicates that the client understands the effects of exercise on insulin demand? A. "I will carry a high-fat, high-calorie food, such as a cookie." B. "I will administer 1 unit of lispro insulin prior to playing tennis." C. "I will eat a 15-gram carbohydrate snack before playing tennis." D. "I will need to rest for a while during tennis if I feel sweaty or shaky."

ANSWER: 3 The food should be a simple sugar food because the fat content of a high-fat food will delay the absorption of the glucose in the food. Taking insulin prior to activity will lower the blood glucose level such that hypoglycemia can occur. Excessive exercise without sufficient carbohydrates can result in unexpected hypoglycemia. Feeling sweaty or shaky during exercise indicates hypoglycemia; a complex carbohydrate should be consumed, and the client should rest.

The client with type 1 DM is scheduled for major surgery in the morning. The nurse on the night shift observes that the client's daily insulin dose remains the same as previously given. Which nursing action is most appropriate? A. Notify the prescribing HCP about the client's surgery and ask about any insulin changes. B. Write an order to decrease the morning insulin dose by one-half of the prescribed dose. C. Do nothing; the HCP would want the client to receive the usual insulin dose prior to surgery. D. Have the day shift nurse check a morning glucose level and, if normal, hold the insulin dose.

ANSWER: A A. Because the client will be NPO for surgery, the nurse should verify the insulin type and dose to be administered to prevent a hypoglycemic reaction. B. An RN is unable to prescribe medications. The nurse could write the order based on protocol or standing orders, but this is not noted in the option. C. Doing nothing could cause a hypoglycemic reaction because the client will be NPO for surgery. D. Holding the morning dose of insulin can cause hyperglycemia, leading to DKA. Even without food, glucose levels increase from hepatic glucose production. Clients with type 1 DM require insulin 24 hours a day.

The nurse reviews the HCP's orders for the newly admitted client diagnosed with DKA. Which order should the nurse question? A. Administer D5W intravenously (IV) at 125 mL per hour B. Administer KCL 10 mEq in 100 mL NaCl IV now C. Give sodium bicarbonate IV per pharmacy dosing if arterial pH is less than 7.0 D. Start regular insulin infusion per protocol; titrate based on hourly glucose level

ANSWER: A A. In DKA, the blood glucose level is above 300 mg/dL. Additional glucose will increase the glucose level further. Initially 0.45% or 0.9% sodium chloride (NaCl) is administered for fluid resuscitation. Glucose may be added when blood glucose levels approach 250 mg/dL. B. Insulin will drive potassium into the cells, so potassium chloride (KCL) is administered to prevent life-threatening hypokalemia. C. Normal arterial pH is 7.35 to 7.45. Sodium bicarbonate will reverse the severe acidosis. D. IV insulin will correct the hyperglycemia and hyperketonemia. Tight glucose control can be maintained by hourly glucose checks and adjusting the insulin infusion dose.

The client residing in a long-term care facility has type 2 DM and is sick with the stomach flu. The client's blood glucose is 245 mg/dL. Which action should the nurse take next? A. Have the client void and check the urine for ketones. B. Keep the client NPO until blood glucose levels decline. C. Immediately contact the client's health care provider. D. Continue to monitor blood glucose levels every 6 hours.

ANSWER: A A. The nurse should check the client's urine for ketones whenever the blood glucose level is greater than 240 mg/dL. B. The client should continue to eat meals as tolerated and not be placed on NPO. If a regular diabetic diet is not tolerated, easily digested foods and regular soda can be substituted. C. The ketone should be known before contacting the HCP; some agencies have protocols in place for treating elevated glucose levels when the client with diabetes is ill. D. Sick-day management of the client with diabetes includes more frequent monitoring of blood glucose levels to at least every 2-4 hours, not every 6 hours.

The home health nurse is completing the first home visit for the elderly Hispanic client newly diagnosed with type 2 DM. The client has been instructed on self-administering NPH and regular insulin in the morning and at suppertime. What information should the nurse reinforce when teaching the client? Select all that apply. A. Inspect the feet and between the toes daily. B. Use magnifying devices to read small print. C. Perform a hemoglobin A1c test once a week. D. Eat a 15-gram carbohydrate snack at bedtime. E. Inject 1 unit of NPH insulin after eating a snack.

ANSWER: A, B, D A. Diabetes, diabetic complications, and increased mortality have been reported to occur at a higher rate in Hispanics compared with non-Hispanic whites of the same age. Therefore, careful daily skin assessment is necessary. Neuropathy, PVD, and immunocompromise can result in diabetic foot ulcer and complications. B. Magnifying devices are available if the client is unable to read small print to prevent dosing errors. C. Blood is drawn in the laboratory to check the A1c. D. Regular insulin peaks in 2 to 3 hours, and NPH insulin peaks in 4 to 12 hours after administration. A bedtime snack will cover the insulin peak to prevent hypoglycemia. E. Only short-acting (regular) or rapid-acting insulin (aspart or lispro), not NPH insulin, would be administered to cover for additional carbohydrates if the client were on a carbohydrate-counting regimen with insulin coverage. This would be prescribed by the HCP.

The nurse is assessing the client who has type 2 DM. Which findings indicate to the nurse that the client is experiencing HHNS? Select all that apply. A. Serum osmolality 364 mOsm/kg B. Blood glucose level 160 mg/dL C. Very dry mucous membranes D. Blood pressure of 90/42 mm Hg E. Urine output 500 mL past 8 hours

ANSWER: A, C, D A. A serum osmolality of 364 mOsm/kg is elevated (normal 275-295 mOsm/kg); the extremely high blood glucose levels in HHNS increase serum osmolality. B. Although a blood glucose level of 160 mg/dL is elevated, the blood glucose levels in HHNS are extremely elevated, usually 600 to 1200 mg/dL. C. Very dry mucous membranes indicate dehydration. Persistent hyperglycemia in HHNS causes osmotic diuresis, a loss of water and electrolytes, and extreme dehydration. D. A BP of 90/42 indicates hypotension from loss of water and electrolytes in HHNS. E. Urine output of 500 mL in 8 hours is normal; in HHNS polyuria occurs from the high glucose levels and osmotic diuresis.

The nurse evaluates the client who is being treated for DKA. Which finding indicates that the client is responding to the treatment plan? A. Eyes sunken and skin flushed B. Skin moist with rapid elastic recoil C. Serum potassium level is 3.3 mEq/L D. ABG results are pH 7.25, PaCO2 30, HCO3 17

ANSWER: B A. Sunken eyes and flushing are signs of dehydration. B. Moist skin and good skin turgor indicate that dehydration secondary to hyperglycemia is resolving. C. Normal serum potassium levels are 3.5 to 5.0 mEq/L; a level of 3.3 mEq/L is low. D. The abnormal ABGs indicate compensating metabolic acidosis; the pH, PaCO2, and HCO3 are all low.

The nurse administers a usual morning dose of 4 units of regular insulin and 8 units of NPH insulin at 7:30 a.m. to the client with a blood glucose level of 110 mg/dL. Which statements regarding the client's insulin are correct? A. The onset of the regular insulin will be at 7:45 a.m. and the peak at 1:00 p.m. B. The onset of the regular insulin will be at 8:00 a.m. and the peak at 10:00 a.m. C. The onset of the NPH insulin will be at 8:00 a.m. and the peak at 10:00 a.m. D. The onset of the NPH insulin will be at 12:30 p.m. and the peak at 11:30 p.m.

ANSWER: B A. The onset of regular insulin (short acting) is one-half to 1 hour, not 15 minutes; its peak is 2 to 3 hours, not 5.5 hours. B. The onset of regular insulin (short acting) is one-half to 1 hour, and the peak is 2 to 3 hours. The onset of NPH insulin (intermediate acting) is 2 to 4 hours, and the peak is 4 to 12 hours. C. The onset of NPH insulin (intermediate acting) is 2 to 4 hours, not 30 minutes; its peak is 4 to 12 hours, not 2.5 hours. D. The onset of NPH insulin (intermediate acting) is 2 to 4 hours, not 5 hours; the peak is 4 hours, which is within the normal peak time of 4 to 12 hours.

The nurse administers 15 units of glargine insulin at 2100 hours to the client when the client's fingerstick blood glucose reading is 110 mg/dL. At 2300, an NA reports that an evening snack was not given because the client was sleeping. Which instruction by the nurse is most appropriate? A. "You will need to wake the client to check the blood glucose and then give a snack. All diabetics get a snack at bedtime." B. "It is not necessary for this client to have a snack; glargine insulin is absorbed over 24 hours and doesn't have a peak." C. "The next time the client wakes up, check a blood glucose level and then give a 15-gram carbohydrate snack." D. "I will notify the HCP; a snack at this time will affect the next blood glucose level and dose of glargine insulin."

ANSWER: B A. Waking the client to check the blood glucose and then giving a snack is unnecessary. All diabetics do not need a bedtime snack. B. The onset of glargine (Lantus) is 1 hour; it has no peak action, and it lasts for 24 hours. Glargine lowers the blood glucose by increasing transport into cells and promoting the conversion of glucose to glycogen. Because it has no peak action, a bedtime snack is unnecessary. C. Checking the blood glucose level and then giving a snack the next time the client wakes up is unnecessary. D. Glargine is administered once daily, the same time each day, to maintain relatively constant concentrations over 24 hours. It is unnecessary to notify the HCP.

The nurse determined that the client's fluid volume deficit from HHNS has resolved. Which serum laboratory finding led to the nurse's conclusion? A. Decreased glucose B. Decreased sodium C. Decreased osmolality D. Decreased potassium

ANSWER: C A. A decrease in serum glucose indicates that the hyperglycemia is resolving, but not the fluid volume deficit. B. Serum sodium values should increase, not decrease, with treatment. C. Extreme hyperglycemia produces severe osmotic diuresis; loss of sodium, potassium, and phosphorus; and profound dehydration. Consequently, hyperosmolality occurs. A normalizing of the serum osmolality indicates that the fluid volume deficit is resolving. D. Potassium values should increase, not decrease, with treatment.

A friend brings the older adult homeless client to a free health screening clinic. The friend is unable to continue administering the client's morning and evening insulin dose for treating type 1 DM. When advocating for this client, which action by the nurse is most appropriate? A. Notify Adult Protective Services about the client's condition and living situation. B. Ask where the client lives and whether someone else could administer the insulin. C. Arrange with a local homeless shelter to have someone give the insulin injections. D. Have the client return to the screening clinic morning and evening to receive the injections.

ANSWER: C A. Adult Protective Services is an agency that investigates actual or potential abuse. B. Option 2 is data gathering and not advocacy. C. The nurse advocates by ensuring that the client has access to health care services. The nurse should contact a social worker whose role it is to make placement arrangements. D. A screening clinic is not a permanent clinic where health care services are provided.

The client taking NPH insulin at 0800 reports feeling anxious and shaky in the midafternoon. Which intervention is best for the nurse to initiate? A. Have the client rate the level of anxiety. B. Give the client's prn dose of lorazepam. C. Check the client's fingerstick blood glucose level. D. Advise the client to sit in a recliner to relax.

ANSWER: C A. Having the client rate the level of anxiety will delay obtaining a fingerstick blood glucose; the problem may not be anxiety but hypoglycemia. B. The problem may not be anxiety but hypoglycemia; administering lorazepam (Ativan) should not be considered until hypoglycemia is ruled out. C. The best intervention is to check a fingerstick blood glucose level because anxiety and shakiness in the midafternoon when taking NPH insulin (Humulin N) could indicate hypoglycemia; NPH insulin peaks in 6-8 hours after administration. D. The problem may not be anxiety but hypoglycemia; having the client sit in a recliner to relax should not be considered until hypoglycemia is ruled out.

Two hours after taking a regular morning dose of regular insulin, the client presents to a clinic with diaphoresis, tremors, palpitations, and tachycardia. Which nursing action is most appropriate? A. Check pulse oximetry; if 94% or less, start oxygen at 2 L per nasal cannula. B. Give a baby aspirin and one nitroglycerin tablet; obtain an electrocardiogram. C. Check blood glucose level; provide carbohydrates if less than 70 mg/dL (3.8 mmol/L). D. Check heart rate; if the HR is above 120 beats per minute, give atenolol 25 mg orally.

ANSWER: C A. The symptoms do not suggest a respiratory problem; giving oxygen when saturations are 94% is unnecessary. B. Although diaphoresis, palpitations, and tachycardia are symptoms of both hypoglycemia and cardiac problems, the client had taken insulin 2 hours earlier. Treating the low blood sugar first rather than giving aspirin and nitroglycerin will likely resolve the client's symptoms. C. Regular insulin (Humulin R) peaks in 2 to 4 hours after administration. The client's symptoms suggest hypoglycemia, so a blood glucose level should be checked and carbohydrates given if low. D. The Atenolol (Tenormin) should never be given without also knowing the BP. Test-taking Tip: When selecting an answer, consider that regular insulin peaks in 2 to 4 hours after administration.

The nurse is planning to address diabetic meal planning with the client recently diagnosed with type 1 DM. Which action should the nurse take first? A. Encourage use of non-nutritive sweeteners that contain no calories. B. Emphasize the importance of keeping regular mealtimes every day. C. Teach the client how to count the carbohydrates in meals and snacks. D. Ask the client to identify favorite foods and the client's usual mealtimes.

ANSWER: D A. Addressing nutritive and non-nutritive sweeteners with the client is important because nutritive sweeteners contain calories and non-nutritive sweeteners are calorie free; however, this is an intervention; assessment is first. B. If the client is taking insulin, keeping regular mealtimes will help to cover the peak times of insulin. This is important to address but is an intervention; assessment is first. C. One method for dosing insulin is based on the number of carbohydrates consumed. This is important to address but is an intervention; assessment is first. D. Asking about favorite foods and usual mealtimes is an assessment question used in obtaining a thorough diet history; the nurse should take this action first prior to beginning teaching. Test-taking Tip: Assessment is the first step in the nursing process and should be accomplished first.

The nurse obtains a fingerstick blood glucose reading of 48 mg/dL for the client with type 1 DM. The client is to receive 6 units of regular and 10 units of NPH insulin now. Which is the nurse's best immediate intervention? A. Administer the insulin that is due now. B. Call the lab for a STAT serum glucose level. C. Have the client choose foods for a meal now. D. Provide juice with 15 grams of carbohydrates.

ANSWER: D A. Administering insulin when hypoglycemia is already present could cause unconsciousness and death. B. Calling the lab to obtain a STAT serum glucose level will delay the client's treatment for hypoglycemia. C. Having the client choose foods for a meal will delay the client's treatment for hypoglycemia. D. Normal blood glucose level is 70-110 mg/dL. Hypoglycemia is treated with 15 to 20 g of a simple (fast-acting) carbohydrate, such as 4 to 6 oz of fruit juice or 8 oz of low-fat milk.

The nurse is interviewing four clients. Which client is at the greatest risk for developing type 2 DM? A. 56-year-old Hispanic female B. 40-year-old Asian American female C. 25-year-old obese Caucasian male D. 38-year-old Native American male

ANSWER: D A. Although the incidence of DM is higher among Hispanics than Caucasians, Native Americans have the highest risk. B. The incidence of DM is low among Asian Americans. C. The young client who is obese does have an increased risk and should be explored for DM, but the Native American client is at greatest risk. The incidence of DM is higher among Native Americans than Caucasians, and the Native American client is older. D. The nurse should further explore whether the Native American male client has developed DM. Research has shown that the highest incidence of DM is among Native Americans.

The nurse is planning to complete noon assessments for four assigned clients with type 1 DM. All of the clients received subcutaneous insulin aspart at 0800 hours. Place the clients in the order of priority for the nurse's assessment. A. The 60-year-old client who is nauseated and has just vomited for the second time B. The 45-year-old client who is dyspneic and has chest pressure and new-onset atrial fibrillation C. The 75-year-old client with a fingerstick blood glucose level of 300 mg/dL D. The 50-year-old client with a fingerstick blood glucose level of 70 mg/dL

ANSWER: D A. Both the middle-of-the-night and morning blood glucose readings are within normal ranges. B. A middle-of-the-night blood glucose between 50 and 60 mg/dL and a morning level of 48 and 62 mg/dL both indicate hypoglycemia. C. The above-normal blood glucose in the middle of the night and morning hyperglycemia are signs of Dawn phenomenon. D. The nurse should conclude that the low blood glucose in the middle of the night (45-62 mg/dL) and a rebound morning hyperglycemia (200-305 mg/dL) are signs of Somogyi phenomenon, also known as Somogyi effect. Test-taking Tip: To narrow the options, associate Somogyi with a rebound effect (a low, then a high). You can remember this by thinking about a gym when you see the word somogyi.

The client with type 2 DM is scheduled for cardiac rehabilitation exercises (cardiac rehab). The nurse notes that the client's blood glucose level is 300 mg/dL and that the urine is positive for ketones. How should the nurse proceed? A. Send the client to cardiac rehab; exercise will lower the client's glucose level. B. Give insulin; send the client for exercises with a 15-gram carbohydrate snack. C. Delay cardiac rehab; blood glucose levels will decrease too much with exercise. D. Cancel cardiac rehab; blood glucose levels will increase further with exercise.

ANSWER: D A. Exercise in the presence of hyperglycemia does not lower the blood glucose level. B. Administering insulin may be an option, but the blood glucose level should be known before sending the client to cardiac rehab. C. Exercise, even if delayed, will not lower the blood glucose level in the presence of hyperglycemia. D. Exercising with blood glucose levels exceeding 250 mg/dL and ketonuria increases the secretion of glucagon, growth hormone, and catecholamines, causing the liver to release more glucose.

The physician orders 36 units of NPH and 12 units of regular insulin. The nurse plans to administer these drugs using one (1) syringe. Tip: Identify the steps in this procedure by listing them in priority order. 1. Invert regular insulin bottle and withdraw regular insulin dose 2. Inject air equal to regular dose into regular dose 3. Invert NPH vial and withdraw NPH dose 4. Inject air equal to NPH dose into NPH vial

Correct answer: 2, 4, 3, 1 The correct order of answers is shown above. Rationale: A short-acting (regular insulin) and intermediate-acting insulin (NPH) are compatible. They can be mixed by drawing the regular insulin first followed by the NPH.

A nurse is caring for a client admitted to the ER with DKA. In the acute phase the priority nursing action is to prepare to: A. Administer regular insulin intravenously B. Administer 5% dextrose intravenously C. Correct the acidosis D. Apply an electrocardiogram monitor

Correct answer: A. Administer regular insulin intravenously Option A: Lack (absolute or relative) of insulin is the primary cause of DK1. Options B and C: Treatment consists of insulin administration (regular insulin), IV fluid administration (normal saline initially), and potassium replacement, followed by correcting acidosis. Option D: Applying an electrocardiogram monitor is not a priority action.

A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in the ER. Which finding would a nurse expect to note as confirming this diagnosis? A. Elevated blood glucose level and a low plasma bicarbonate B. Decreased urine output C. Increased respiration and an increase in pH D. Comatose state

Correct answer: A. Elevated blood glucose level and a low plasma bicarbonate Option A: In diabetic acidosis, the arterial pH is less than 7.35. plasma bicarbonate is less than 15mEq/L, and the blood glucose level is higher than 250mg/dl and ketones are present in the blood and urine. Options B and C: The client would be experiencing polyuria, and Kussmaul's respirations would be present. Option D: A comatose state may occur if DKA is not treated, but coma would not confirm the diagnosis

Glucose is an important molecule in a cell because this molecule is primarily used for: A. Extraction of energy B. Synthesis of protein C. Building of genetic material D. Formation of cell membranes

Correct answer: A. Extraction of energy Glucose catabolism is the main pathway for cellular energy production.

An external insulin pump is prescribed for a client with DM. The client asks the nurse about the functioning of the pump. The nurse bases the response on the information that the pump: A. Gives a small continuous dose of regular insulin subcutaneously, and the client can self-administer a bolus with an additional dosage from the pump before each meal. B. It is timed to release programmed doses of regular or NPH insulin into the bloodstream at specific intervals. C. It is surgically attached to the pancreas and infuses regular insulin into the pancreas, which in turn releases the insulin into the bloodstream. D. It continuously infuses small amounts of NPH insulin into the bloodstream while regularly monitoring blood glucose levels.

Correct answer: A. Gives a small continuous dose of regular insulin subcutaneously, and the client can self-administer a bolus with an additional dosage from the pump before each meal. An insulin pump provides a small continuous dose of regular insulin subcutaneously throughout the day and night, and the client can self-administer a bolus with additional dosage from the pump before each meal as needed. Regular insulin is used in an insulin pump. An external pump is not attached surgically to the pancreas.

A nurse is preparing a plan of care for a client with diabetes mellitus who has hyperglycemia. The priority nursing diagnosis would be: A. High risk for deficient fluid volume B. Deficient knowledge: disease process and treatment C. Imbalanced nutrition: less than body requirements D. Disabled family coping: compromised

Correct answer: A. High risk for deficient fluid volume Option A: Increased blood glucose will cause the kidneys to excrete the glucose on the urine. This glucose is accompanied by fluids and electrolytes, causing osmotic diuresis leading to dehydration. This fluid loss must be replaced when it becomes severe. Options B, C, and D are not related specifically to the issue of the question.

The nurse is admitting a patient diagnosed with type 2 diabetes mellitus. The nurse should expect the following symptoms during an assessment, except: A. Hypoglycemia B. Frequent bruising C. Ketonuria D. Dry mouth

Correct answer: A. Hypoglycemia Option A: Hypoglycemia does not occur in type 2 diabetes unless the patient is on insulin therapy or taking other diabetes medication. Option B: Type 2 diabetes can affect blood circulation which makes it easier for the skin to bruise. Option C: The presence of ketones in the urine happens due to a lack of available insulin. Option D: Losing a lot of fluids caused by frequent urination can lead to dehydration hence patients can develop dry mouth.

A client with diabetes mellitus states, "I cannot eat big meals; I prefer to snack throughout the day." The nurse should carefully explain that: A. Regulated food intake is basic to control B. Salt and sugar restriction is the main concern C. Small, frequent meals are better for digestion D. Large meals can contribute to a weight problem

Correct answer: A. Regulated food intake is basic to control An understanding of the diet is imperative for compliance. A balance of carbohydrates, proteins, and fats usually apportioned over three main meals and two between meals snacks need to be tailored to the client's specific needs, with due regard for activity, diet, and therapy.

Albert, a 35-year-old insulin-dependent diabetic, is admitted to the hospital with a diagnosis of pneumonia. He has been febrile since admission. His daily insulin requirement is 24 units of NPH. Every morning Albert is given NPH insulin at 0730. Meals are served at 0830, 1230, and 1830. The nurse expects that the NPH insulin will reach its maximum effect (peak) between the hours of: A. 1130 and 1330 B. 1330 and 1930 C. 1530 and 2130 D. 1730 and 2330

Correct answer: B. 1330 and 1930 The peak time of insulin is the time it is working the hardest to lower the blood glucose. NPH insulin is an intermediate-acting insulin that has an onset of 1 to 3 hours after injection, peaks 4 to 12 hours later, and is effective for about 12 to 16 hours.

Glycosylated hemoglobin (HbA1C) test measures the average blood glucose control of an individual over the previous three months. Which of the following values is considered a diagnosis of pre-diabetes? A. 6.5-7% B. 5.7-6.4% C. 5-5.6% D. >5.6%

Correct answer: B. 5.7-6.4% Option B: Glycosylated hemoglobin levels between 5.7%-6.4% is considered as pre-diabetes. Option A: Glycosylated hemoglobin levels over 6.5 % are considered diagnostic of diabetes. Options C and D: Glycosylated hemoglobin levels less than 5.6 % are normal.

A client is taking NPH insulin daily every morning. The nurse instructs the client that the most likely time for a hypoglycemic reaction to occur is: A. 2-4 hours after administration B. 6-14 hours after administration C. 16-18 hours after administration D. 18-24 hours after administration

Correct answer: B. 6-14 hours after administration The peak time of insulin is the time it is working the hardest to lower the blood glucose. NPH insulin is an intermediate-acting insulin that has an onset of 1 to 3 hours after injection, peaks 4 to 12 hours later, and is effective for about 12 to 16 hours.

When a client is experiencing diabetic ketoacidosis, the insulin that would be administered is: A. Human NPH insulin B. Human regular insulin C. Insulin lispro injection D. Insulin glargine injection

Correct answer: B. Human regular insulin Regular insulin (Humulin R) is short-acting insulin and is administered via IV with an initial dose of 0.3 units/kg, followed by 0.2 units/kg 1 hour later, followed by 0.2 units/kg every 2 hours until blood glucose becomes <13.9 mmol/L (<250 mg/dL). At this point, the insulin dose should be decreased by half, to 0.1 units/kg every 2 hours, until the resolution of DKA.

The nurse is teaching a client regarding the administration of insulin as part of the discharge plan. Which of the following insulin has the most rapid onset of action? A. insulin regular (Humulin R) B. lispro (Admelog) C. glargine (Toujeo) D. insulin NPH (Humulin N)

Correct answer: B. Lispro (Admelog) Option B: Lispro is a rapid-acting insulin that works within 15 minutes after injection, a peak of 30-90 minutes, and a duration of 2-4 hours. Option A: Human regular (Humulin R) is a regular or short-acting insulin that usually reaches the bloodstream in 30 minutes, a peak of 2-3 hours, and a duration of 3 to 6 hours. Option C: Glargine (Toujeo) is ultra-long-acting insulin that reaches the bloodstream within 6 hours, has no peak, and duration 36 hours or longer.Option D: Insulin NPH (Humulin N) is an intermediate-acting insulin that reaches the bloodstream about 2 to 4 hours after injection, a peak of 4-12 hours, and duration of 12-18 hours.

Which of the following chronic complications is associated with diabetes? A. Dizziness, dyspnea on exertion, and coronary artery disease B. Retinopathy, neuropathy, and coronary artery disease C. Leg ulcers, cerebral ischemic events, and pulmonary infarcts D. Fatigue, nausea, vomiting, muscle weakness, and cardiac arrhythmias

Correct answer: B. Retinopathy, neuropathy, and coronary artery disease Option B: These are all chronic complications of diabetes. Option A: Dizziness, dyspnea on exertion, and coronary artery disease are symptoms of aortic valve stenosis. Option C: Leg ulcers, cerebral ischemic events, and pulmonary infarcts are complications of sickle cell anemia. Option D: Fatigue, nausea, vomiting, muscle weakness, and cardiac arrhythmias are symptoms of hyperparathyroidism.

A nurse went to a patient's room to do routine vital signs monitoring and found out that the patient's bedtime snack was not eaten. This should alert the nurse to check and assess for: A. Elevated serum bicarbonate and decreased blood pH B. Signs of hypoglycemia earlier than expected C. Symptoms of hyperglycemia during the peak time of NPH insulin D. Sugar in the urine

Correct answer: B. Signs of hypoglycemia earlier than expected. Eating a bedtime snack can prevent blood glucose levels from dropping very low during the night and lessen the Somogyi effect where glucose levels drop significantly between 2:00 a.m. and 3:00 a.m.

A male nurse is providing a bedtime snack for his patient. This is based on the knowledge that intermediate-acting insulins are effective for an approximate duration of: A. 6-8 hours B. 10-14 hours C. 14-18 hours D. 24-28 hours

Correct answer: C. 14-18 hours Option C: Intermediate-acting insulins include Humulin N and Novolin N. They have an onset of two to four hours, peak of 4 to 12 hours, and a duration of 14 to 18 hours. Option A: Regular or short-acting insulins include Humulin R and Novolin R. They have an onset of half an hour, a peak of two to three hours, and a duration of six to eight hours. Option D: Long-acting insulins include Levemir and Lantus. They have an onset of several hours, minimal or no peak, and a duration of 24 hours or more.

A client with type 1 diabetes mellitus has a fingerstick glucose level of 258mg/dl at bedtime. An order for sliding scale insulin exists. The nurse should: A. Call the physician B. Encourage the intake of fluids C. Administer the insulin as ordered D. Give the client 1/2 c. of orange juice

Correct answer: C. Administer the insulin as ordered A value of 258mg/dl is above the expected range of 70-105 mg/dl; the nurse should administer the insulin as ordered.