Chapter 38: Agents to Control Blood Glucose Levels

A client newly diagnosed with type 2 diabetes has attended educational sessions to provide insight into the diagnosis. Which of the client's statements should prompt the nurse to provide further teaching?

"I'm disappointed, but I take some solace in the fact that I won't ever have to have insulin injections." Explanation: Among people with type 2 diabetes, 20% to 30% require exogenous insulin at some point in their lives. Obesity is a major cause, and vigilant treatment can prevent future sequelae. The essence of type 2 diabetes is the pancreas' inability to meet insulin needs.

The nurse has just completed discharge instructions to a client who will be using a pen device to deliver his insulin dose. What statement by the client indicates a need for further instruction?

"If I forget to take my insulin pen, I will be able to use the one that my wife uses." Explanation: Insulin pens are client-specific because the needle may be used multiple times and may be contaminated with blood. Also, the pen is prefilled with a specific type of insulin. The client selects the desired units by turning a dial and listening for a locking ring. The insulin dose is determined by the number of clicks heard. It is a useful method for clients who have poor eyesight.

The client is scheduled to get a breakfast tray at 07:00. At what time should the client receive a prescribed dose of insulin lispro?

06:45 Explanation: With short-acting insulins like lispro, aspart, or glulisine, it is important to inject the medication about 15 minutes before eating.

The nurse assesses a client's blood glucose level after administering insulin. Which result would the nurse interpret as indicative of severe hypoglycemia?

34 mg/dL Explanation: Blood glucose levels below 40 mg/dL are indicative of severe hypoglycemia.

A client who began treatment for type 2 diabetes 8 months ago is now meeting with a diabetic nurse for a scheduled follow-up. How can the nurse best assess the client's glycemic control since beginning treatment?

Assess the most recent hemoglobin A1C levels. Explanation: Health care providers look at the glycosylated hemoglobin (hemoglobin A1C) levels to assess the effectiveness of treatment. Because glucose stays attached to hemoglobin for the life of the red blood cell, which is about 120 days, the hemoglobin A1C level reflects the average blood glucose level over the past 3 months. Reviewing blood glucose readings, measuring the client's random blood glucose, and dialoguing with the client are all therapeutic strategies, but hemoglobin A1C is most accurate.

Insulin binds with and activates receptors on cell membranes. Once insulin-receptor binding occurs, the membranes become highly permeable to glucose. Which action does this enable?

Entry of glucose into the cells Explanation: After insulin-receptor binding occurs, cell membranes become highly permeable to glucose and allow rapid entry of glucose into the cells.

The nurse is providing education to a client who has been prescribed therapy with an antidiabetic medication. During teaching, the nurse will caution the client against heavy intake of which herb?

Garlic Explanation: Garlic has been known to cause hypoglycemia when taken with antidiabetic medications. Anise, basil, and oregano are not noted to carry this risk.

The nurse is preparing to administer 20 units of NPH insulin to a client. Before administering the medication, the nurse should implement which intervention?

Have a colleague confirm the dosage. Explanation: Before administering insulin, client safety requires that two nurses always check the dosage. Assessing the client's understanding of the disease may or may not be appropriate or necessary at this time. Injection sites are not massaged before administration. It is not necessary to assess urine for the presence of glucose.

The health care provider has ordered a change of prescription from rapid-acting insulin to an intermediate-acting type. Which adverse effect must the nurse closely monitor for in the client?

Hypoglycemia Explanation: Changing the type of insulin requires caution, and the client should be carefully monitored for hypoglycemia or hyperglycemia, either of which may occur as the body adjusts to the different pharmacokinetics of the preparation. However, hypoglycemia may cause an increased sympathetic activity and manifest as tachycardia. Lipodystrophy is caused by the breakdown of subcutaneous fat because of repeated insulin injections at the same site. A change of insulin prescription is not known to cause hypotension.

When administering insulin, what would be most appropriate?

Insert the needle at a 45-degree angle for injection. Explanation: The vial should be gently rotated and vigorous shaking is to be avoided to ensure uniform suspension of the insulin. Typically the area is pinched to allow access to the loose connective tissue layer. The needle is inserted at a 45-degree angle for subcutaneous administration. Gentle pressure should be applied at the injection site.

A nurse is presenting an educational event at a local senior citizens' club about diabetes. What would the nurse tell the attendees at the event about diabetes?

It is a complicated disorder that alters the metabolism of glucose. Explanation: Diabetes is a complicated disorder that alters the metabolism of glucose, fats, and proteins affecting many end organs and causing numerous clinical complications. It is part of the metabolic syndrome, a collection of conditions that predispose to cardiovascular disease.

Which would be appropriate to include in teaching a client with type 2 diabetes?

It is possible with weight loss and exercise to discontinue the use of antidiabetic medication. Explanation: Exercise is perhaps the best therapy for the prevention of both type 2 diabetes and the metabolic syndrome. Exercise is an extremely strong hypoglycemic agent.

The nurse admits a client with type 2 diabetes who takes metformin (Glucophage).The nursing diagnosis given is ineffective breathing pattern. What complication of the client's current drug therapy does the nurse believe the client is experiencing?

Lactic acidosis Explanation: When taking metformin, the client is at risk for lactic acidosis, which causes hyperventilation, myalgia, malaise, GI symptoms, or unusual somnolence. Respiratory alkalosis, fluid overload, and hyperkalemia would be unlikely complications with metformin.

After teaching a class about the various drugs used to control blood glucose, the instructor determines that the teaching was successful when the class identifies what as a biguanide?

Metformin Explanation: Metformin is classified as a biguanide. Miglitol is an alpha-glucosidase inhibitor. Tolbutamide is a first generation sulfonylurea. Glipizide is a second generation sulfonylurea.

A nurse is caring for a patient diagnosed with type 2 diabetes. What should the nurse inform the patient are risk factors associated with type 2 diabetes?

Obesity Explanation: The nurse informs the patient that obesity is a risk factor associated with type 2 diabetes. Young age and regular exercise are not risk factors for type 2 diabetes. Polyuria is a symptom of diabetes and not a risk factor leading to type 2 diabetes.

A student asks the nursing instructor what insulin has the quickest therapeutic effect once administered. What would be the best response?

Regular (Humulin R) Explanation: Regular insulin has the quickest onset of 30-60 minutes. PZI and ultralente have an onset of 4-8 hours. NPH has an onset of 60-90 minutes.

The nurse is preparing to administer insulin intravenously to a client with a blood glucose level over 600 mg/dL (33.33 mmol/L). What type of insulin will the nurse most likely give?

Regular insulin Explanation: Regular insulin has rapid onset of action and can be given via IV. It is the drug of choice for acute situations, such as diabetic ketoacidosis. Isophane insulin (NPH) is used for long-term insulin therapy. Lente insulin is an intermediate-acting insulin. Ultralente insulin is a long-acting insulin.

A client diagnosed with diabetic ketoacidosis has been admitted to the intensive care unit. The client is prescribed an intravenous insulin drip, so the nurse knows that what type of insulin will be administered?

Regular. Explanation: Regular insulin (insulin injection) has a rapid onset of action and can be given intravenously. Therefore, it is the insulin of choice during acute situations, such as DKA, severe infection or other illness, and surgical procedures. All the other options are administered subcutaneously.

A nurse is preparing an in-service presentation for a group of staff members on diabetes. Which would the nurse include as the primary delivery system for insulin?

Subcutaneous injection Explanation: Although other delivery systems are available for insulin administration such as the jet injector, insulin pen, and external pump, subcutaneous injection remains the primary delivery system.

After teaching a group of students about the various methods for the delivery of insulin, the instructor determines that the teaching was successful when the students identify which method as most commonly used for administration?

Subcutaneous injection Explanation: Subcutaneous injection currently is the most common method for administering insulin.

When reviewing the medication list of a client being seen in the clinic, the nurse notes that the client is receiving glipizide. Based on the nurse's understanding, this drug is used to treat:

hyperglycemia. Explanation: Glipizide is an antidiabetic agent with the desired action of lowering the blood glucose level. It is used to treat hyperglycemia. It would worsen, not treat, hypoglycemia, and it has no role in treating abnormal potassium levels (hypokalemia or hyperkalemia).

Insulin is a hormone released by the pancreatic beta cells in response to a rise in glucose levels and what else?

incretins Explanation: Insulin is the hormone produced by the pancreatic beta cells of the islets of Langerhans. The hormone is released into circulation when the levels of glucose around these cells rise. It is also released in response to incretins, peptides that are produced in the GI tract in response to food.

A nurse is preparing to administer a rapid-acting insulin. Which medication would the nurse likely administer?

insulin lispro Explanation: Insulin lispro is an example of a rapid-acting insulin. Insulin glargine and insulin detemir are long-acting insulin. Isophane insulin suspension is an intermediate-acting insulin.

A 58-year-old male client, diagnosed with diabetes at age 14, reports having pain in both feet and hands. What is this pain most likely a result of?

peripheral neuropathy Explanation: Pain in the feet and hands is related to changes in small blood vessels resulting in neuropathy. The long-term effect of diabetes can result in an infectious process, but the pain described is not indicative of an infection. Latent autoimmune diabetes of the adult has an onset in adulthood and thus is not a long-term disorder. Hypertension is a long-term chronic effect of diabetes but is not what has been described with pain in the feet and hands.

The nurse is interviewing a client who was diagnosed with type 2 diabetes four months ago. The client does not record glucometer readings. What laboratory test does the nurse anticipate the health care provider will order for this client?

HbA1c Explanation: The nurse anticipates that the glycosylated hemoglobin (HbA1c) will be ordered for this client because it provides an average of the client's blood glucose level for the last three- to four-month period. It will also tell how well controlled the client's blood glucose is. A stat urine for glucose and an FBG in the AM will only indicate the client's current blood glucose level, not how well it is being controlled. An insulin level will not give the information needed to understand the client's control of blood glucose.

The two major classifications of diabetes are type 1 and type 2. What is a distinguishing characteristic of type 1 diabetes?

Lifelong exogenous insulin is required. Explanation: Type 1 diabetes results from an autoimmune disorder that destroys pancreatic beta cells. Insulin is the only effective treatment for type 1 diabetes, because pancreatic beta cells are unable to secrete endogenous insulin and metabolism is severely impaired. Insulin cannot be given orally, because it is destroyed by proteolytic enzymes in the GI tract. Although the onset of type 1 diabetes frequently occurs in childhood, it can also occur in adulthood.

A nurse is caring for a patient with diabetes mellitus who is receiving an oral antidiabetic drug. Which of following ongoing assessments should the nurse perform when caring for this patient?

Observe the patient for hypoglycemic episodes. Explanation: As the ongoing assessment activity, the nurse should observe the patient for hypoglycemic episodes. Documenting family medical history and assessing the patient's skin for ulcers, cuts, and sores on the body is a pre-administration assessment activity performed by the nurse. Lipodystrophy occurs if the sites of insulin injection are not rotated.

After reviewing information about different insulin preparations, a nursing student demonstrates understanding of the information when the student identifies which medication as an example of a long-acting insulin?

insulin glargine Explanation: Insulin glargine is an example of a long-acting insulin. Insulin lispro and insulin aspart are rapid-acting insulin. Isophane insulin suspension is an intermediate-acting insulin.

A client's current condition requires rapid reduction of blood sugar levels. Which type of insulin will have the most rapid onset of action?

insulin lispro Explanation: Insulin lispro has a 15-minute onset of action. NPH, 70/30, and regular insulin have longer onsets of action, a later peak, and a longer duration of action.

Rosiglitazone is being considered for the treatment of diabetes in an adult client. Before the initiation of rosiglitazone therapy, the nurse should review what laboratory work recently drawn?

liver enzymes Explanation: Rosiglitazone has been associated with hepatotoxicity and requires monitoring of liver enzymes. Liver function tests (e.g., serum aminotransferase enzymes) should be checked before starting therapy and every 2 months for 1 year, then periodically. Platelets, d-dimer, and tests of renal function are less significant to the safety and efficacy of treatment.

When considering the management of diabetic ketoacidosis (DKA), what type of insulin can be administered intravenously?

regular Explanation: Regular insulin (insulin injection) has a rapid onset of action and can be given intravenously. Therefore, it is the insulin of choice during acute situations, such as DKA, severe infection or other illness, and surgical procedures. All the other options are administered subcutaneously.

A client with diabetes is undergoing testing for glycosylated hemoglobin. The nurse instructs the client that this test measures average blood glucose over what time period?

the past 3 or 4 months Explanation: Glycosylated hemoglobin measures glucose control over the past 3 to 4 months. When blood glucose levels are high, glucose molecules attach to hemoglobin in the red blood cell. The longer the hyperglycemia lasts, the more glucose binds to the red blood cell and the higher the glycosylated hemoglobin. This binding lasts for the life of the red blood cell (about 4 months) so the other time frames would not be accurate.

The nurse is caring for a client who is taking insulin. The nurse suspects the client is experiencing hypoglycemia when the client displays what signs?

weakness, sweating, and decreased mentation. Explanation: Symptoms of hypoglycemia include shakiness, dizziness or light-headedness, sweating, nervousness or irritability, sudden changes in behavior or mood, weakness, pale skin, and hunger. The other signs are more consistent with hyperglycemia.

A nurse is assigned to administer glargine to a patient at a health care facility. What precaution should the nurse take when administering glargine?

Avoid mixing glargine with other insulin. Explanation: When administering glargine to the patient, the nurse should avoid mixing it with other insulin or solutions. It will precipitate in the syringe when mixed. If glargine is mixed with another solution, it will lose glucose control, resulting in decreased effectiveness of the insulin. Glargine is administered via SC once daily at bedtime. The nurse should not shake the vial vigorously before withdrawing insulin. The vial should be gently rotated between the palms of the hands and tilted gently end-to-end immediately before withdrawing the insulin. The nurse administers insulin from vials at room temperature. Vials are stored in the refrigerator if it is to be stored for about three months for later use.

A nurse at a health care facility is assigned to administer insulin to the patient. Which intervention should the nurse perform before administering each insulin dose?

Inspect the previous injection site for inflammation. Explanation: The nurse should check the previous injection site before administering each insulin dose. The injection sites should be rotated to prevent lipodystrophy. Prefilled syringes should not be kept horizontally; they should be kept in a vertical or oblique position to avoid plugging the needle. The nurse checks for symptoms of myalgia or malaise when administration of metformin leads to lactic acidosis. Insulin should be kept at room temperature for administration. Insulin is refrigerated if it needs to be stored for up to three months for later use.

The nurse monitoring a client receiving insulin glulisine notices the client has become confused, diaphoretic, and nauseated. The nurse checks the client's blood glucose and it is 60 mg/dL (3.33 mmol/L). Which can a nurse give to treat a client with a hypoglycemic episode? (Select all that apply.)

Orange or other fruit juice Glucose tablets Hard candy Explanation: Methods of terminating a hypoglycemic reaction include the administration of one or more of the following: orange or other fruit juice, hard candy or honey, glucose tablets, glucagon, or glucose 10 percent or 50 percent IV.

A nurse is instructing a patient in the administration of regular insulin by the subcutaneous route. Which strategy would the nurse suggest if the goal is to promote absorption of the regular insulin?

Select one anatomic area for regular insulin injections and then use serial locations within that area. Explanation: To promote the absorption of regular insulin, one anatomic area should be selected for subcutaneous injections. Serial locations within that anatomic area are then chosen to rotate the exact injection site. Injection sites should not be rotated by using different anatomic areas each day, because this would substantially change the absorption of the insulin and the patient's blood glucose levels. Using one injection site regularly may lead to lipodystrophy. Regular insulin is administered about 30 to 60 minutes before eating a meal, not after.

A patient at a health care facility has been prescribed diazoxide for hypoglycemia due to hyperinsulinism. What adverse reactions to the drug should the nurse monitor for in the patient?

Tachycardia Explanation: The nurse should monitor for tachycardia, congestive heart failure, sodium and fluid retention, hyperglycemia, and glycosuria as the adverse reactions in the patient receiving diazoxide drug therapy. Myalgia, fatigue, and headache are the adverse reactions observed in patients undergoing pioglitazone HCl drug therapy. Flatulence is one of the adverse reactions found in patients receiving metformin drug therapy. Epigastric discomfort is one of the adverse reactions observed in patients receiving acetohexamide drugs.