Medsurg: Diabetes Mellitus

The home health nurse is completing the admission assessment for a 76-year-old client diagnosed with Type 2 diabetes that must be controlled with 70/30-combination insulin. Which intervention should be included in the plan of care? 1. Assess the client's ability to read small print. 2. Monitor the client's serum PT level. 3. Teach the client how to perform a hemoglobin A1c test daily. 4. Instruct the client to check the feet weekly.

**1. Age-related visual changes and diabetic retinopathy occur that could lead to the client having difficulty in reading and draw- ing up insulin dosage accurately. 2. The PT level is monitored for clients receiving Coumadin, an anticoagulant, which is not ordered for client with diabetes, Type 1 or 2. 3. Glycosylated hemoglobin is a serum blood test usually performed in a laboratory, not in the client's home. The hemoglobin Alc is performed every three (3) months. Self-monitoring blood glucose (SMBG) should be taught to the client. 4. The client's feet should be checked daily, not weekly. In a week the client could have developed gangrene from an injury that the client did not realize he or she had. TEST-TAKING HINT: Always notice the age of a client if it is given because this is often impor- tant when determining the correct answer for the question. Be sure to read the adjectives such as "weekly," instead of "daily."

The nurse administered 28 units of Humulin N, an intermediate-acting insulin, to a client diagnosed with Type 1 diabetes at 1600. Which action should the nurse implement? 1. Ensure the client eats the bedtime snack. 2. Determine how much food the client ate at lunch. 3. Perform a glucometer reading at 0700. 4. Offer the client protein after administering insulin.

**1. Humulin N peaks in 6-8 hours, making the client at risk for hypoglycemia around midnight, which is why the client should receive a bedtime snack. This snack will prevent nighttime hypoglycemia. 2. The food intake at lunch will not affect the client's blood glucose level at midnight. 3. The client's glucometer reading should be done around 2100 to assess the effectiveness of insulin at 1600. 4. Humulin N is an intermediate-acting insulin that has an onset in 2-4 hours but does not peak until 6-8 hours. TEST-TAKING HINT: Remember to look at the adjective or descriptor. Intermediate-acting insulin gives the reader a clue that anything intermediate, instead of longer-acting, action would be incorrect.

The elderly client is admitted to the intensive care department diagnosed with severe HHS. Which collaborative intervention should the nurse include in the plan of care? 1. Infuse 0.9% normal saline intravenously. 2. Administer intermediate-acting insulin. 3. Perform blood glucometer checks daily. 4. Monitor arterial blood gas results.

**1. The initial fluid replacement is O.9% normal saline (an isotonic solution) intra- venously, followed by 0.45% saline. The rate depends on the client's fluid volume status and physical health, especially that of the heart. 2. Regular insulin, not intermediate, is the insulin of choice because of its quick onset and peak in two (2) to four (4) hours. 3. Blood glucometer checks are done every one (1) hour or more often in clients with HHS who are receiving regular insulin drips. 4. Arterial blood gases are not affected in HHS because there is no breakdown of fat resulting in ketones that cause metabolic acidosis. TEST-TAKING HINT: The test taker should elim- inate option "3" based on the word "daily." In the ICU with a client who is very ill, most checks would be more often than daily. Remember to look at adjectives; "intermedi- ate" in option "2" is the word that eliminates this as a possible correct answer.

The diabetic educator is teaching a class on diabetes Type 1 and is discussing sick-day rules. Which interventions should the diabetes educator include in the discussion? Select all that apply. 1. Take diabetic medication even if unable to eat the client's normal diabetic diet. 2. If unable to eat, drink liquids that are equal to the client's normal caloric intake. 3. It is not necessary to notify the health-care provider if ketones are in the urine. 4. Test blood glucose levels and test urine ketones once a day and keep a record. 5. Call the health-care provider if glucose levels are higher than 180 mg/dL.

**1. The most important issue to teach clients is to take insulin even if they are unable to eat. Glucose levels are increased with ill- ness and stress. **2. The client should drink liquids such as regular cola, orange juice, or regular gela- tin, which provide enough glucose to pre- vent hypoglycemia when receiving insulin. 3. Ketones indicate a breakdown of fat and must be reported to the HCP because they can lead to metabolic acidosis. 4. Blood glucose levels and ketones must be checked every three (3) to four (4) hours, not daily. **5. The HCP should be notified if the blood glucose level is this high. Regular insulin may need to be prescribed to keep the blood glucose level within acceptable range. TEST-TAKING HINT: This is an alternate-type question that may have more than one correct answer. The test taker should read all options and determine if it is an intervention that is appropriate.

The client is admitted to the ICD diagnosed with DKA. Which interventions should the nurse implement? Select all that apply. 1. Maintain adequate ventilation. 2. Assess fluid volume status. 3. Administer intravenous potassium. 4. Check for urinary ketones. 5. Monitor intake and output.

**1. The nurse should always address the airway when a client is seriously ill **2. The client must be assessed for fluid volume deficit and then for fluid volume excess after fluid replacement is started. **3. The electrolyte imbalance of primary concern is depletion of potassium. **4. Ketones are excreted in the urine; levels are documented from negative to large amount. Ketones should be monitored frequently. **5. The nurse must ensure that the client's fluid intake and output are equal. TEST-TAKING HINT: The test taker must select all that apply. Do not try to outguess the item writer. In some instances all options are correct.

The client diagnosed with Type 1 diabetes is found lying unconscious on the floor of the bathroom. Which intervention should the nurse implement first? 1. Administer 50% dextrose IVP. 2. Notify the health-care provider. 3. Move the client to the ICD. 4. Check the serum glucose level.

**1. The nurse should assume the client is hypoglycemic and administer IVP dextrose, which will rouse the client immediately. If the collapse is the result of hyperglycemia, this additional dextrose will not further injure the client. 2. The health-care provider may or may not need to be notified, but this would not be the first intervention. 3. The client should be left in the client's room, and 50% dextrose should be administered first. 4. The serum glucose level requires a venipuncture, which will take too long. A blood glucometer reading may be obtained, but the nurse should first treat the client, not the machine. The glucometer only reads "low" after a certain point, and a serum level would be needed to confirm exact glucose level. TEST-TAKING HINT: The question is requesting the test taker to select which intervention should be implemented first. All four options could be possible interventions, but only one is first. The test taker should select the intervention that will directly treat the client; do not select a diagnostic test.

The nurse is developing a care plan for the client diagnosed with Type 1 diabetes. The nurse identifies the problem "high risk for hyperglycemia related to noncompliance with the medication regimen." Which statement would be an appropriate short-term goal for the client? 1. The client will have a blood glucose level between 90 and 140 mg/dL. 2. The client will demonstrate appropriate insulin injection technique. 3. The nurse will monitor the client's blood glucose levels four times a day. 4. The client will maintain normal kidney function with 30 mL/hr urine output.

**1. The short-term goal must address the response part of the nursing diagnosis, which is "high risk for hyperglycemia," and this blood glucose level is within acceptable ranges for a client who is noncompliant. 2. This is an appropriate goal for a knowledge- deficit nursing diagnosis. Noncompliance is not always the result of knowledge deficit. 3. Note that this is the nurse implementing an intervention and the question asks for a goal, which addresses the problem of "high risk for hyperglycemia." 4. The question asks for a short-term goal and this is an example of a long-term goal. TEST-TAKING HINT: Remember the nursing diagnosis consists of a problem related to an etiology. The goals must address the problem and the interventions must address the etiol- ogy. Always remember a short-term goal is usually a goal that can be met during the hospitalization, and the long-term goal may take weeks, months, or even years.

The client diagnosed with Type 2 diabetes comes to the emergency department. The client's blood glucose is 680 mg/dL and the client is diagnosed with HHS. Which ques- tion should the nurse ask the client to determine the cause of this acute complication? 1. When is the last time you took your insulin? 2. When did you have your last meal? 3. Have you had some type of infection lately? 4. How long have you had diabetes?

1. A client with Type 2 diabetes usually is prescribed oral hypoglycemic medications, not insulin. 2. The client could not eat enough food to cause a 680 mg/dL blood glucose level; therefore this question does not need to be asked. **3. The most common precipitating factor is infection. The manifestations may be slow to appear, with onset ranging from 24 hours to 2 weeks. 4. This would not help determine the cause of this client's HHS. TEST-TAKING HINT: If the test taker does not know the answer to this question, the test taker could possibly relate acute complication and realize that a medical problem might cause this and select infection, option "3."

The nurse is caring for a client with long-term Type 2 diabetes and is assessing the feet. Which assessment data would warrant immediate intervention by the nurse? 1. The client has crumbling toenails. 2. The client has athlete's feet. 3. The client has a necrotic big toe. 4. The client has thickened toenails.

1. Crumbling toenails indicate tinea unguium, which is a fungus infection of the toenail. 2. Athlete's foot is a fungal infection that is not life threatening. **3. A necrotic big toe indicates "dead" tissue. The client does not feel pain in the lower extremity and does not realize there has been an injury and therefore does not seek treatment. Increased blood glucose levels decrease oxygen supply that is needed to heal the wound and increase the risk for developing an infection. 4. Big, thick toenails are fungal infections and would not require immediate intervention by the nurse; 50% of the adult population has this. TEST-TAKING HINT: The test taker should select the option that indicates to the nurse that this is possibly a life-altering complication or some type of assessment data that the health-care provider should be informed of immediately. Remember "warrants immediate intervention."

Which electrolyte replacement should the nurse anticipate being ordered by the health-care provider in the client diagnosed with DKA who has just been admitted to the ICD? 1. Glucose. 2. Potassium. 3. Calcium. 4. Sodium.

1. Glucose is elevated in DKA; therefore, the HCP would not be replacing glucose. **2. The client in DKA loses potassium from increased urinary output, acidosis, cata- bolic state, and vomiting. Replacement is essential for preventing cardiac dysrhyth- mias secondary to hypokalemia. 3. Calcium is not affected in the client with DKA. 4. The IV that is prescribed 0.9% normal saline has sodium, but it is not specifically ordered for sodium replacement. This is an isotonic solution. TEST-TAKING HINT: Option "1" should be eliminated because the problem with DKA is elevated glucose so the HCP would not be replacing it. The test taker should use physiology knowledge and realize potassium is in the cell.

The client with Type 2 diabetes controlled with biguanide oral diabetic medication is scheduled for a computed tomography (CT) with contrast of the abdomen to evaluate pancreatic function. Which intervention should the nurse implement? 1. Provide a high-fat diet 24 hours prior to test. 2. Hold the biguanide medication for 48 hours prior to test. 3. Obtain an informed consent form for the test. 4. Administer pancreatic enzymes prior to the test.

1. High-fat diets are not recommended for clients diagnosed with diabetes, and food does not have an effect on a CT scan with contrast. **2. Biguanide medication must be held for a test with contrast medium because it in- creases the risk of lactic acidosis, which leads to renal problems. 3. Informed consent is not required for a CT scan. The admission consent covers routine diagnostic procedures. 4. Pancreatic enzymes are administered when the pancreas cannot produce amylase and lipase, not when the beta cells cannot produce insulin. TEST-TAKING HINT: The test taker could elimi- nate option "1" because high-fat diets are not recommended for any client. Because the stem specifically refers to the biguanide medication and CT contrast, a good choice would address both of these. Option "2" discusses both the medication and the test.

The nurse is discussing ways to prevent diabetic ketoacidosis with the client diagnosed with Type 1 diabetes. Which instruction would be most important to discuss with the client? 1. Refer the client to the American Diabetes Association. 2. Do not take any over-the-counter medications. 3. Take the prescribed insulin even when unable to eat because of illness. 4. Be sure to get your annual flu and pneumonia vaccines.

1. The American Diabetic Association is an excellent referral, but the nurse should discuss specific ways to prevent DKA. 2. The client should be careful with OTC medications, but this intervention would not help prevent the development of DKA. **3. Illness increases blood glucose levels; therefore the client must take insulin and drink high-carbohydrate fluids such as regular Jell-O, regular popsicles, and orange juice. 4. Vaccines are important to help prevent illness, but regardless of whether the client gets these vaccines, the client can still develop diabetic ketoacidosis. TEST-TAKING HINT: The words "most impor- tant" in the stem of the question indicate that one or more option may be appropriate instructions but only one is the priority inter- vention.

The client diagnosed with Type 1 diabetes has a glycosylated hemoglobin (A1c) of 8.1%. Which interpretation should the nurse make based on this result? 1. This result is below normal levels. 2. This result is within acceptable levels. 3. This result is above recommended levels. 4. This result is dangerously high.

1. The acceptable level for an A1c for a client with diabetes is between 6% and 7%, which corresponds to a 120-140 mg/dL average blood glucose level. 2. This result is not within acceptable levels for the client with diabetes, which is 6% to 7%. **3. This result parallels a serum blood glucose level of approximately 180 to 200 mg/dL. An A1c is a blood test that reflects average blood glucose levels over a period of 2-3 months; clients with elevated blood glucose levels are at risk for developing long-term complications. 4. An A1c of 13% is dangerously high; it reflects a 300-mg/dL average blood glucose level over the past 3 months. TEST-TAKING HINT: The test taker must know normal and abnormal diagnostic laboratory values. Lab values vary depending on which lab performs the test.

The client received 10 units of Humulin R, a fast acting insulin, at 0700. At 1030 the unlicensed nursing assistant tells the nurse the client has a headache and is really acting "funny." Which action should the nurse implement first? 1. Instruct the assistant to obtain blood glucose level. 2. Have the client drink eight (8) ounces of orange juice. 3. Go to the client's room and assess the client for hypoglycemia. 4. Prepare to administer one amp 50% Dextrose intravenously.

1. The blood glucose level should be obtained, but it is not the first intervention. 2. If it is determined that the client is having a hypoglycemic reaction, orange juice would be appropriate. **3. Regular insulin peaks in 2-4 hours. There- fore, the nurse should think about the possibility that the client is having a hypo- glycemic reaction and should assess the client. The nurse should not delegate nursing tasks to an assistant if the client is unstable. 4. Dextrose 50% is only administered if the client is unconscious and the nurse suspects hypo- glycemia. TEST-TAKING HINT: When answering a question that requires the nurse to implement an intervention first, all four options will be interventions that are appropriate for the situation but only one answer should be implemented first. The test taker must apply the nursing process, which states assessment of the first intervention.

The nurse is discussing the importance of exercising to a client diagnosed with Type 2 diabetes whose diabetes is well controlled with diet and exercise. Which information should the nurse include in the teaching about diabetes? 1. Eat a simple carbohydrate snack before exercising. 2. Carry peanut butter crackers when exercising. 3. Encourage the client to walk 20 minutes three (3) times a week. 4. Perform warmup and cooldown exercises.

1. The client diagnosed with Type 2 diabetes who is not taking insulin or oral agents does not need extra food before exercise. 2. The client with diabetes who is at risk for hypoglycemia when exercising should carry a simple carbohydrate, but this client is not at risk for hypoglycemia. 3. Clients with diabetes that is controlled by diet and exercise must exercise daily at the same time and in the same amount to control the glucose level. **4. All clients who exercise should perform warmup and cooldown exercises to help prevent muscle strain and injury. TEST-TAKING HINT: The "1" and "2" options apply directly to clients diagnosed with dia- betes and "3" and "4" options do not directly address clients diagnosed with diabetes. The reader could narrow the choices by either eliminating or including the two similar options.

The nursing assistant on the medical floor tells the primary nurse that the client diag- nosed with DKA wants something else to eat for lunch. What action should the nurse implement? 1. Instruct the assistant to get the client additional food. 2. Notify the dietician about the client's request. 3. Ask the assistant to obtain a glucometer reading. 4. Tell the assistant that the client cannot have anything else.

1. The client is on a special diet and should not have any additional food. **2. The client will not be compliant with the diet if he or she is still hungry. Therefore, the nurse should request the dietician to talk to the client to try and adjust the meals so that the client will adhere to the diet. 3. There is no need for the assistant to check the client's glucose level. 4. The client is on a special diet. The nurse needs to help the client maintain compliance with the medical treatment and should refer the client to the dietician. TEST-TAKING HINT: The test taker should select the option that attempts to ensure that the client maintains compliance. The test taker should remember to work with members of the multidisciplinary health-care team.

The client diagnosed with HHS was admitted yesterday with a blood glucose level of 780 mg/dL. The client's blood glucose level is now 300 mg/dL. Which intervention should the nurse implement? 1. Increase the regular insulin IV drip. 2. Check the client's urine for urinary ketones. 3. Provide the client with a therapeutic diabetic meal. 4. Notify the HCP to obtain an order to decrease insulin therapy.

1. The regular intravenous insulin is continued because ketosis is not present, as with DKA. 2. The client diagnosed with Type 2 diabetes does not excrete ketones in HHS because there is enough insulin to prevent fat breakdown but not enough to lower blood glucose. 3. The client may or may not feel like eating,but it is not the appropriate intervention when the blood glucose level is reduced to 300 mg/dL. **4. When the glucose level is decreased to around 300 mg/dL, the regular insulin infu- sion therapy is decreased. Subcutaneous insulin will be administered per sliding scale. TEST-TAKING HINT: When two (2) options are the opposite of each other, they can either be eliminated or they can help eliminate the other two options as incorrect answers. Options "2" and "3" do not have insulin in the answer; therefore they should be eliminated as possible answers.

Which arterial blood gas would the nurse expect in the client diagnosed with diabetic ketoacidosis? 1. pH 7.34, PaO2 99, PaCO2 48, HCO3 24. 2. pH 7.38, PaO2 95, PaCO2 40, HCO3 22. 3. pH 7.46, PaO2 85, PaCO2 30, HCO3 26. 4. pH 7.30, PaO2 90, PaCO2 30, HCO3 18.

1. This ABG indicates respiratory acidosis, which would not be expected. 2. This ABG is normal, which would not be expected. 3. This ABG indicates respiratory alkalosis, which would not be expected. **4. This ABG indicates metabolic acidosis, which is what is expected in a client that is in diabetic ketoacidosis. TEST-TAKING HINT: The client must know normal ABGs to be able to correctly answer this question. Normal ABGs are pH 7.35-7.45; PaO2 80-100; PaCO2 35-45; HCO3 22-26.

The charge nurse is making client assignments in the intensive care department. Which client should be assigned to the most experienced nurse? 1. The client with Type 2 diabetes who has a blood glucose level of 348 mg/dL. 2. The client diagnosed with Type 1 diabetes who is experiencing hypoglycemia. 3. The client with DKA who has multifocal premature ventricular contractions. 4. The client with HHS who has a plasma osmolarity of 290 mOsm/L.

1. This blood glucose level is elevated, but not life threatening, in the client diagnosed with Type 2 diabetes. Therefore, a less experienced nurse could care for this client. 2. Hypoglycemia is an acute complication of Type 1 diabetes, but it can be managed by frequent monitoring, so a less experienced nurse could care for this client. **3. Multifocal PVCs, which are secondary to hypokalemia and which can occur in clients with DKA, are an emergency and can be life threatening. This client needs an expe- rienced nurse. 4. A plasma osmolarity of 280-300 mOsm/L is within normal limits; therefore, a less experi- enced nurse could care for this client. TEST-TAKING HINT: The test taker must select the client that has an abnormal, unexpected, or life-threatening sign/symptom for the disease process and assign this client to the most experienced nurse.

Which assessment data indicate that the client diagnosed with diabetic ketoacidosis is responding to the medical treatment? 1. The client has tented skin turgor and dry mucous membranes. 2. The client is alert and oriented to date, time, and place. 3. The client's ABGs results are pH 7.29, PaCO2 44, HCO3 15. 4. The client's serum potassium level is 3.3 mEq/L.

1. This indicates the client is dehydrated, which does not indicate that the client is getting better. **2. The client's level of consciousness can be altered because of dehydration and acido- sis. If the client's sensorium is intact, the client is getting better and responding to the medical treatment. 3. These ABGs indicate metabolic acidosis; there- fore the client is not responding to treatment. 4. This potassium level is low and indicates hypokalemia, which shows the client is not responding to medical treatment. TEST-TAKING HINT: Responding to medical treatment is asking the test taker to determine which data indicate the client is getting better. The correct answer will be normal data and the other three (3) options will be signs/symp- toms of the disease process or condition.

The nurse at a freestanding health clinic is caring for a 56-year-old client who is home- less and is a Type 2 diabetic controlled with insulin. Which action is an example of client advocacy? 1. Ask the client if he has somewhere he can go and live. 2. Arrange for someone to give him his insulin at a local homeless shelter. 3. Notify Adult Protective Services about the client's situation. 4. Ask the health-care provider to take the client off insulin because he is homeless.

1. This is an example of interviewing the client; it is not an example of client advocacy. 2. Client advocacy focuses support on the client's autonomy. Even if the nurse disagrees with his living on the street, it is the client's right. Arranging for someone to give him his insulin provides for his needs and allows his choices. 3. Adult Protective Services is an organization that investigates any actual or potential abuse in adults. This client is not being abused by anyone. 4. The client needs the insulin to control the diabetes and talking to the HCP about taking him off a needed medication is not an example of advocacy. TEST-TAKING HINT: Remember to make sure the test taker knows what the question is asking and the definition of the terms.

The client diagnosed with Type 2 diabetes is admitted to the intensive care department with hyperosmolar hyperglycemic nonketonic state coma (HHS). Which assessment data would the nurse expect the client to exhibit? 1. Kussmaul's respirations. 2. Diarrhea and epigastric pain. 3. Dry mucous membranes. 4. Ketone breath odor.

1. This occurs with diabetic ketoacidosis (DKA) as a result of the breakdown of fat, resulting in ketones. 2. Diarrhea and epigastric pain are not associated with HHS. **3. Dry mucous membranes are a result of the hyperglycemia and occur with both HHS and DKA. 4. This occurs with DKA as a result of the break- down of fat, resulting in ketones. TEST-TAKING HINT: The test taker must be able to differentiate between HHS (Type 2) and DKA (Type 1), which primarily is the result of the breakdown of fat and results in an increase in ketones that causes a decrease in pH, result- ing in metabolic acidosis.

The client, an 18-year-old female, 54 tall, weighing 113 kg, comes to the clinic for a wound on her lower leg that has not healed for the last two (2) weeks. Which disease process would the nurse suspect that the client has developed? 1. Type 1 diabetes. 2. Type 2 diabetes. 3. Gestational diabetes. 4. Acanthosis nigricans.

1. Type 1 diabetes usually occurs in young clients who are underweight. In this disease, there is no production of insulin from the beta cells in the pancreas. People with Type 1 diabetes are insulin-dependent with a rapid onset of symp- toms, including polyuria, polydipsia, and polyphagia. **2. Type 2 diabetes is a disorder that usually occurs around the age of 40, but it is now being detected in children and young adults as a result of obesity and sedentary life- styles. Wounds that do not heal are a hall- mark sign of Type 2 diabetes. This client weighs 248.6 pounds and is short. 3. Gestational diabetes is diabetes that occurs during pregnancy. 4. Acanthosis nigricans (AN), dark pigmentation and skin creases in the neck, is a sign of hyper- insulinemia. The pancreas is secreting excess amounts of insulin as a result of excessive caloric intake. It is identified in young children and is a precursor to the development of Type 2 diabetes. TEST-TAKING HINT: The test taker must be aware of kilogram and pounds; the stem is asking about a disease process and acantho- sis nigricans is a clinical manifestation of a disease, not a disease itself. Therefore, the test taker should not select this as a correct answer.

The client diagnosed with Type 1 diabetes is receiving Humalog, a rapid-acting insulin, by sliding scale. The order reads blood glucose level: 150, 0 units; 151-200, 3 units; 201-250, 6 units; 251, contact health-care provider. The unlicensed nursing assistant reports to the nurse that the client's glucometer reading is 189. How much insulin should the nurse administer to the client?

Three (3) units. The client's result is 189, which is between 151 and 200, so the nurse should administer 3 units of Humalog insulin subcutaneously. TEST-TAKING HINT: The test taker must be aware of the way the HCPs write medication orders. HCPs order insulin in a sliding scale according to a range of blood glucose levels.