Pharmacology 3 - Sherpath
A patient who has type 2 diabetes will begin taking glipizide. Which statement by the patient is concerning to the nurse?
"I may continue to have a glass of wine with dinner." *Glipizide is a sulfonylurea antidiabetic agent and can cause a disulfiram-like reaction when combined with alcohol. Patients should be taught to avoid alcohol while taking this medication. The initial dosing is once daily with breakfast. There is no drug interaction with grapefruit juice. Patients will need to monitor their blood glucose.
The nurse is providing patient education about glucocorticoid therapy to a patient preparing to be discharged home. Which statement made by the patient best demonstrates understanding of glucocorticoid therapy?
"I may take 2/3 of the dose in the morning and 1/3 in the afternoon." *Patients should be instructed to follow the prescribed dosing schedule. Some prescribers recommend dividing the daily dose by taking 2/3 in the morning and 1/3 in the evening. Other prescribers recommend taking the entire daily dose at bedtime. Taking the dose at breakfast, dividing the dose in half, and taking a dose with each meal are not recommended dosing schedules.
A nurse counsels a patient with diabetes who is starting therapy with an alpha-glucosidase inhibitor. The patient should be educated about the potential for which adverse reactions?
- Flatulence - Diarrhea *Acarbose and miglitol frequently cause flatulence, cramps, abdominal distention, borborygmus (rumbling bowel sounds), and diarrhea.
A nurse is educating the staff nurses about ketoacidosis. To evaluate the group's understanding, the nurse asks, "Which sign or symptom would not be consistent with ketoacidosis?" The group gives which correct answer?
Blood glucose level of 60 *A patient with DKA has a high glucose level; therefore, a glucose level of 60 would not be consistent with DKA. A blood glucose of 600, acidosis, and ketones in the urine are consitent with DKA.
A patient is given 1 mg of dexamethasone at 11:00 pm; a plasma cortisol level recorded at 8:00 pm the next day is normal. The nurse knows that this is an indication that the patient has what condition?
Cushing's syndrome *The overnight dexamethasone suppression test, which is performed by administering dexamethasone as described, is used to diagnose Cushing's syndrome. In normal individuals, dexamethasone suppresses the release of adrenocorticotropic hormone (ACTH), thereby suppressing the synthesis and releast of cortisol, which results in a low cortisol level. In patients with Cushing's syndrome, the cortisol level is normal or only mildly low. This is not an indication of Addison's disease, which is diagnosed by administering cosyntropin. Neither test is useful for diagnosing congenital adrenal hyperplasia or secondary adrenal insufficiency.
Which statement is correct about the contrast between acarbose and miglitol?
Miglitol has not been associated with hepatic dysfunction *Unlike acarbose, miglitol has not been associated with hepatic dysfunction. Sucrose should not be used to treat hypoglycemia with miglitol. Miglitol is more effective in African American patients. Miglitol has gastrointestinal side effects.
An adolescent recently attended a health fair and had a serum glucose test. The patient telephones the nurse and says, "My level was 125. Does that mean I have diabetes?" What is the nurse's most accurate response?
"Unless you were fasting for longer than 8 hours, this does not necessarily mean you have diabetes." *If a person has not fasted for 8 hours, a blood sugar level of 125 would be considered normal, because it is less than 200 for a random sampling. Also, a person must have positive outcomes on two separate days to be diagnosed with diabetes. This patient does not need to have an oral glucose tolerance test, becase the 125 reading is so far below 200, which would require further work-up. However, this also is not conclusive evidence that the patient does not have diabetes.
A patient who has been newly diagnosed with adrenal hormone deficiency will begin taking hydrocortisone. The nurse provides teaching for this patient. Which statement by the patient indicates understanding of the teaching?
"When I am sick, I should take three times the normal dose for 3 days in a row." *Patients who take hydrocortisone as replacement need to be taught to increase their daily dose during times of stress, because the drug causes adrenal suppression, and the adrenals will not be able to release cortisone as usual during stress. A general rule of thumb is the "3 by 3 rule": take 3 times the usual dose for 3 days when sick. The daily dose is usually given once in the morning; if late-day fatigue occurs, patients may split the dose and take 2/3 in the morning and 1/3 in the late afternoon or evening. Treatment is lifetime. Side effects are uncommon when hydrocortisone is given in therapeutic doses.
A nurse provides dietary counseling for a patient newly diagnosed with type 1 diabetes. Which instruction should be included?
"You should use carbohydrate counting approach to maintain glycemic control." *Patients with diabetes should be given intensive insulin therapy education using a carbohydrate counting or experience-based estimation approach in achieving glycemic control. A patient with diabetes cannot eat any foods desired and then cover the glucose increase with a sliding scale of regular insulin. Evidence suggests that there is not an ideal percentage of calories that should be ingested from carbohydrate, fat, or protein. Every patient with diabetes must be assessed individually to determine the number of total calories the person should have daily. The total caloric intake should be spread evenly throughout the day, with meals spaced 4 to 5 hours apart.
A patient newly diagnosed with diabetes expresses concern about losing her vision. Which interventions should be included in the plan of care to reduce this risk?
- Ways to reduce hyperglycemic episodes - Emphasis on the importance of taking antihypertensive drugs consistently - Smoking cessation *Tighter glycemic control and fewer hyperglycemic episodes have been correlated with fewer complications. Smoking cessation and strict compliance with any drugs prescribed for hypertension also help reduce the risk of complications. The use of contraception or a prokinetic drug is not related to a reduced risk of vision loss in patients with diabetes.
A patient with arthritis is admitted to the hospital. The patient's serum glucose level is 350, and the BP is 182/98. The nurse notes that the patient's face appears rounded and puffy. The patient complains of feeling weak. What will the nurse do?
Ask which drugs the patient takes for arthritis. *Many patients with arthritis are treated with glucocorticoids. Because the doses necessary to suppress inflammation are larger than the physiologic doses used to treat adrenal insufficiency, patients can develop signs of cortisol excess with cushingoid symptoms. This patient has an elevated glucose level, hypertension, and the characteristic moon facies and muscle weakness of Cushing's syndrome; therefore, the nurse would be correct to ask about the medications the patient takes for arthritis. A pituitary carcinoma could be the cause but is less likely. Ketoconazole is used after chemotherapy and radiation thearpy in the treatment of a pituitary adenoma. This patient does not show signs of Addison's disease.
An elderly patient who has type 2 diabetes has a history of severe hypoclycemia. The patient's spouse asks the nurse what the optimum A1C level is for the patient. Which is correct?
Below 8.0 *For patients with history of sever hypoglycemia and those with a limited life expectancy or advanced micro- or macrovascular complications, the target A1C should be below 8.0. For most other patients with diabetes, the target is 7.0 and below.
To manage her diabetes appropriately and ensure a good fetal outcome, the pregnant woman with diabetes will need to alter her diet by
Eating her meals and snacks on a fixed schedule *It is more important to have a fixed meal schedule than equal division of food intake. Approximately 45% of the food eaten should be in the form of carbs. Having a fixed meal schedule will provide the woman and the fetus with a steadier blood sugar level, provide better balance with insulin administration, and help prevent complications
The nurse assesses a newly diagnosed patient for short-term complications of diabetes. What does this assessment include?
Evaluation for hyperglycemia, hypoglycemia, and ketoacidosis *High blood sugar, low blood sugar, and ketoacidosis are short-term complications of diabetes. Microvascular and macrovascular complications, such as peripheral neuropathy, are long-term complications of diabetes. Arterial insufficiency and atherosclerosis also are long-term complications of diabetes.
What is the most reliable measure for assessing diabetes control over the preceding 3-month period?
Glycosylated hemoglobin level *The glycosylated hemoglobin level tells much about what the plasma glucose concentration has been, on average, over the previous 2 - 3 months. The SMBG graph report is done by the patient and indicates each blood sugar level the patient has on a daily basis. It is not reliable as the glycosylated hemoglobin level, because the equipment used might not be accurate and the testing may not reflect actual measurements 100% of the time. The patient's report of blood sugar levels is not considered as accurate as the glycosylated homeglobin level for the same reason that the SMBG is not. One fasting blood glucose level indicates the patient's blood sugar level for that one time when it was obtained.
A patient with type 1 diabetes is eating breakfast at 7:30 am. Blood sugars are on a sliding scale and are ordered before a meal and at bedtime. The patient's blood sugar level is 317. Which formulation of insulin should the nurse prepare to administer?
Lispro *Regular insulin is indicated for sliding scale coverage. Insulin is definitely indicated for this high blood sugar level. NPH is used for scheduled insulin doses and is a longer-acting insulin. A 70/30 mix is also used for scheduled insulin coverage.
What is the most important nursing action before discharge for a mother who is apprehensive about giving her child insulin?
Observe the mother while she administers an insulin injection. *Although reviewing side effects is important, this could be done over the phone or by the pharmacist when the medication is picked up. This is important but not directly relevant to the mother's concern (talking about a rotation schedule). It is important that the nurse evaluate the mother's ability to give the insulin injection before discharge. Watching her give the injection to the child will give the nurse an opportunity to offer assistance and correct any errors. This is important but not as important as having the mother demonstrate the procedure (the importance of follow-up care).
Insulin glargine is prescribed for a hospitalized patient who has diabetes. When will the nurse expect to administer this drug?
Once daily at bedtime *Glargine insulin is indicated for once daily subcutaneous administration to treat adults with type 2 diabetes. According to the package labeling, the once-daily injection should be given at bedtime. Glargine insulin should not be given more than once a day, although some patients require bid dosing to achieve a full 24 hours of basal coverage.
Which statement is accurate about the long-term complications of diabetes?
Optimal control of both types of diabetes reduces the risk of eye, kidney, and nerve damage. *In both types of diabetes, optimal control of the disease slows the development of microvascular complications. Short-term complications are more apt to result from hypoglycemia and ketoacidosis. Patients with type 2 diabetes have fewer complications if their blood sugar level is optimally controlled. Hypoglycemia does not occur more frequently in patients with optimally controlled type 1 diabetes.
A patient who has been taking 25 mg of hydrocortisone each morning for several months reports feeling fatigued late in the day each day. What will the nurse tell the patient to discuss with the provider?
Splitting the daily dose into a morning and an afternoon dose *Patients generally take hydrocortisone once daily in the morning to mimic the body's natural cortisol release cycle. However, some patients develop fatigue late in the day. These patients may split the daily dose, taking 2/3 in the morning and 1/3 in the afternoon or early evening. Mineralocorticoids are given to maintain intravascular volume and regulate sodium, potassium, and hydrogen, so adding this drug would not help with fatigue. Fatigue is not a sign of steroid toxicity. Increasing the dose is not indicated.
The nurse working on a high-acuity medical-surgical unit is prioritizing care for four patients who were just admitted. Which patient should the nurse assess first?
The NPO patient with a blood glucose of 80 who just received 20 units of 70/30 Novolin insulin. *The NPO patient with hypoglycemia who just received 70/30 Novolin insulin takes priority, because this patient needs to consume a good source of glucose immediately or perhaps the NPO status will be discontinued for this shift. The digoxin may be withheld for the patient with a pusle of 58 bpm, but this is not a priority action. The patient with a headache needs to be followed up, but because the BP is 136/92, the headache is probably not caused by the hypertension. The patient with an allergy to penicillin will not have a reaction to the vancomycin.
A patient with type 1 diabetes who takes insulin reports taking propranolol for hypertension. Why is the nurse concerned?
The beta blocker can mask the symptoms of hypoglycemia. *Beta blockers can delay awareness of and response to hypoglycemia by masking signs associated with stimulation of the sympathetic nervous system that hypoglycemia normally causes. Furthermore, beta blockade impairs glycogenolysis, which is one means by which the body can counteract a fall in blood glucose; beta blockers, therefore, can worsen insulin-induced hypoglycemia. Propranolol does not cause insulin resistance. The incidence of DKA is not increased by concurrent use of propranolol and insulin. Insulin requirements are not increased because of receptor blocking by propranolol.
A patient with type 1 diabetes reports mixing NPH and regular insulin to allow for one injection. What should the nurse tell the patient?
This is an acceptable practice. *NPH insulin is the only insulin suitable for mixing with short-acting insulins, such as insulin aspart. These insulins are compatible and are mixed frequently for management of diabetics. The overall potency of each insulin is not increased by mixing them. Insulin glargine cannot be mixed with any other insulin for administration.
What is the best time for the nurse to assess the peak effectiveness of subcutaneously administered regular insulin?
Two hours after administration *The peak action for regular (short-acting) insulin is 2 to 3 hours after aministration. The duration of regular (short-acting) insulin is only 3 - 6 hours. Peak aciton occurs 2 - 3 hours after insulin is administered. Onset of action is 30 - 60 minutes.
A patient who has chronic adrenal insufficiency is admitted to the hospital for an open cholecystectomy. The nurse obtaining the admission history learns that the patient takes hydrocortisone 25 mg PO daily in the morning. The patient's surgery is scheduled for the next morning. The nurse will expect an order to:
administer hydrocortisone 50 mg IV before surgery. *Patients who take steroids need extra steroid before situations that cause stress, such as surgery. Failure to administer the increased dose can prove fatal. For surgeries that cause moderate stress, such as a cholecystectomy, patients should be given 50 mg of hydrocortisone intravenously the day of the procedure, followed by a taper over 1 to 2 days to the usual replacement dose. Giving the usual dose or giving an increased oral dose is not indicated.
