Med Surge CH 46, 10, 17
A client with diabetic ketoacidosis has been brought into the ED. Which intervention is not a goal in the initial medical treatment of diabetic ketoacidosis?
Administer glucose. Insulin is given intravenously. Insulin reduces the production of ketones by making glucose available for oxidation by the tissues and by restoring the liver's supply of glycogen. As insulin begins to lower the blood glucose level, the IV solution is changed to include one with glucose. Periodic monitoring of serum electrolytes and blood glucose levels is necessary. Isotonic fluid is instilled at a high volume, for example, 250 to 500 mL/hour for several hours. The rate is adjusted once the client becomes rehydrated and diuresis is less acute. Potassium replacements are given despite elevated serum levels to raise intracellular stores.
Which instruction about insulin administration should a nurse give to a client?
"Always follow the same order when drawing the different insulins into the syringe." The nurse should instruct the client to always follow the same order when drawing the different insulins into the syringe. Insulin should never be shaken because the resulting froth prevents withdrawal of an accurate dose and may damage the insulin protein molecules. Insulin should never be frozen because the insulin protein molecules may be damaged. The client doesn't need to discard intermediate-acting insulin if it's cloudy; this finding is normal.
Which instruction about insulin administration should a nurse give to a client?
"Always follow the same order when drawing the different insulins into the syringe." The nurse should instruct the client to always follow the same order when drawing the different insulins into the syringe. Insulin should never be shaken because the resulting froth prevents withdrawal of an accurate dose and may damage the insulin protein molecules. Insulin should never be frozen because the insulin protein molecules may be damaged. The client doesn't need to discard intermediate-acting insulin if it's cloudy; this finding is normal.
A newly admitted client with a diagnosis of type 1 diabetes asks the nurse what caused their diabetes. When the nurse is explaining to the client the etiology of type 1 diabetes, what process should the nurse describe?
"Destruction of special cells in the pancreas causes a decrease in insulin production. Glucose levels rise because insulin normally breaks it down." Type 1 diabetes is characterized by the destruction of pancreatic beta cells, resulting in decreased insulin production, unchecked glucose production by the liver, and fasting hyperglycemia. Also, glucose derived from food cannot be stored in the liver and remains circulating in the blood, which leads to postprandial hyperglycemia. Type 2 diabetes involves insulin resistance and impaired insulin secretion. The body does not "make" glucose.
A 1200-calorie diet and exercise are prescribed for a client with newly diagnosed type 2 diabetes. The nurse is teaching the client about meal planning using exchange lists. The teaching is determined to be effective based on which statement by the client?
"For dinner I ate a 3-ounce hamburger on a bun, with ketchup, pickle, and onion; a green salad with 1 teaspoon Italian dressing; 1 cup of watermelon; and a diet soda." There are six main exchange lists: bread/starch, vegetable, milk, meat, fruit, and fat. Foods within one group (in the portion amounts specified) contain equal numbers of calories and are approximately equal in grams of protein, fat, and carbohydrate. Meal plans can be based on a recommended number of choices from each exchange list. Foods on one list may be interchanged with one another, allowing for variety while maintaining as much consistency as possible in the nutrient content of foods eaten. For example, 2 starch = 2 slices bread or a hamburger bun, 3 meat = 3 oz lean beef patty, 1 vegetable = green salad, 1 fat = 1 tbsp salad dressing, 1 fruit = 1 cup watermelon; "free" items like diet soda are optional.
After teaching a client with type 1 diabetes who is scheduled to undergo an islet cell transplant, which client statement indicates successful teaching?
"I might need insulin later on but probably not as much or as often." Transplanted islet cells tend to lose their ability to function over time, and approximately 70% of recipients resume insulin administration in 2 years. However, the amount of insulin and the frequency of its administration are reduced because of improved control of blood glucose levels.
Which statement indicates that a client with diabetes mellitus understands proper foot care?
"I'll wear cotton socks with well-fitting shoes." The client demonstrates understanding of proper foot care if he states that he'll wear cotton socks with well-fitting shoes because cotton socks wick moisture away from the skin, helping to prevent fungal infections, and well-fitting shoes help avoid pressure areas. Aching isn't a common sign of foot problems; however, a tingling sensation in the feet indicates neurovascular changes. Injecting insulin into the foot may lead to infection. The client shouldn't go barefoot. Doing so can cause injury.
A nurse is preparing to administer insulin to a child who's just been diagnosed with type 1 diabetes. When the child's mother stops the nurse in the hall, she's crying and anxious to talk about her son's condition. The nurse's best response is:
"I'm going to give your son some insulin. Then I'll be happy to talk with you." Attending to the mother's needs is a critical part of caring for a sick child. In this case however, administering insulin in a prompt manner supersedes the mother's needs.
A nurse prepares teaching for a client with newly-diagnosed diabetes. Which statements about the role of insulin will the nurse include in the teaching?
"Insulin permits entry of glucose into the cells of the body." "Insulin promotes synthesis of proteins in various body tissues." "Insulin promotes the storage of fat in adipose tissue." Insulin is a hormone secreted by the endocrine part of the pancreas. In addition to lowering blood glucose by permitting entry of glucose into the cells, insulin also promotes protein synthesis and the storage of fat in adipose tissue. Somatostatin exerts a hypoglycemic effect by interfering with glucagon from the pancreas and the release of growth hormone from the pituitary.
A nurse is teaching a client recovering from diabetic ketoacidosis (DKA) about management of "sick days." The client asks the nurse why it is important to monitor the urine for ketones. Which statement is the nurse's best response?
"Ketones accumulate in the blood and urine when fat breaks down in the absence of insulin. Ketones signal an insulin deficiency that will cause the body to start breaking down stored fat for energy." Ketones (or ketone bodies) are by-products of fat breakdown in the absence of insulin, and they accumulate in the blood and urine. Ketones in the urine signal an insulin deficiency and that control of type 1 diabetes is deteriorating. When almost no effective insulin is available, the body starts to break down stored fat for energy.
A client newly diagnosed with diabetes mellitus asks why he needs ketone testing when the disease affects his blood glucose levels. How should the nurse respond?
"Ketones will tell us if your body is using other tissues for energy." The nurse should tell the client that ketones are a byproduct of fat metabolism and that ketone testing can determine whether the body is breaking down fat to use for energy.
Which instruction should a nurse give to a client with diabetes mellitus when teaching about "sick day rules"?
"Test your blood glucose every 4 hours." The nurse should instruct a client with diabetes mellitus to check his blood glucose levels every 3 to 4 hours and take insulin or an oral antidiabetic agent as usual, even when he's sick. If the client's blood glucose level rises above 300 mg/dl, he should call his physician immediately. If the client is unable to follow the regular meal plan because of nausea, he should substitute soft foods, such as gelatin, soup, and custard.
A client has just been diagnosed with type 1 diabetes. When teaching the client and family how diet and exercise affect insulin requirements, the nurse should include which guideline?
"You'll need less insulin when you exercise or reduce your food intake." The nurse should advise the client that exercise, reduced food intake, hypothyroidism, and certain medications decrease insulin requirements. Growth, pregnancy, greater food intake, stress, surgery, infection, illness, increased insulin antibodies, and certain medications increase insulin requirements.
A 16-year-old client newly diagnosed with type 1 diabetes has a very low body weight despite eating regular meals. The client is upset because friends frequently state, "You look anorexic." Which statement by the nurse would be the best response to help this client understand the cause of weight loss due to this condition?
"Your body is using protein and fat for energy instead of glucose." Persons with type 1 diabetes, particularly those in poor control of the condition, tend to be thin because when the body cannot effectively utilize glucose for energy (no insulin supply), it begins to break down protein and fat as an alternate energy source. Patients may be underweight at the onset of type 1 diabetes because of rapid weight loss from severe hyperglycemia. The goal initially may be to provide a higher-calorie diet to regain lost weight and blood glucose control.
A physician orders blood glucose levels every 4 hours for a 4-year-old child with brittle type 1 diabetes. The parents are worried that drawing so much blood will traumatize their child. How can the nurse best reassure the parents?
"Your child will need less blood work as his glucose levels stabilize." Telling the parents that the number of blood draws will decrease as their child's glucose levels stabilize engages them in the learning process and gives them hope that the present discomfort will end as the child's condition improves. Telling the parents that their child won't remember the experience disregards their concerns and anxiety. The nurse shouldn't offer to ask the physician if he can reduce the number of blood draws; the physician needs the laboratory results to monitor the child's condition properly. Although telling the parents that the laboratory technicians are gentle and use tiny needles may be reassuring, it isn't the most appropriate response.
An agitated, confused client arrives in the emergency department. The client's history includes type 1 diabetes, hypertension, and angina pectoris. Assessment reveals pallor, diaphoresis, headache, and intense hunger. A stat blood glucose sample measures 42 mg/dl, and the client is treated for an acute hypoglycemic reaction. After recovery, the nurse teaches the client to treat hypoglycemia by ingesting:
10 to 15 g of a simple carbohydrate. To reverse hypoglycemia, the American Diabetes Association recommends ingesting 10 to 15 g of a simple carbohydrate, such as three to five pieces of hard candy, two to three packets of sugar (4 to 6 tsp), or 4 oz of fruit juice. Then the client should check his blood glucose after 15 minutes. If necessary, this treatment may be repeated in 15 minutes. Ingesting only 2 to 5 g of a simple carbohydrate may not raise the blood glucose level sufficiently. Ingesting more than 15 g may raise it above normal, causing hyperglycemia.
The nurse is administering lispro insulin. Based on the onset of action, how long before breakfast should the nurse administer the injection?
10 to 15 minutes The onset of action of rapid-acting lispro insulin is within 10 to 15 minutes. It is used to rapidly reduce the glucose level.
A nurse is preparing a continuous insulin infusion for a child with diabetic ketoacidosis and a blood glucose level of 800 mg/dl. Which solution is the most appropriate at the beginning of therapy?
100 units of regular insulin in normal saline solution Continuous insulin infusions use only short-acting regular insulin. Insulin is added to normal saline solution and administered until the client's blood glucose level falls. Further along in the therapy, a dextrose solution is administered to prevent hypoglycemia.
A patient who is 6 months' pregnant was evaluated for gestational diabetes mellitus. The doctor considered prescribing insulin based on the serum glucose result of:
138 mg/dL, 2 hours postprandial. The goals for a 2-hour, postprandial blood glucose level are less than 120 mg/dL in a patient who might develop gestational diabetes.
A nurse is teaching a client with diabetes mellitus about self-management of his condition. The nurse should instruct the client to administer 1 unit of insulin for every:
15 g of carbohydrates. The nurse should instruct the client to administer 1 unit of insulin for every 15 g of carbohydrates.
A nurse is caring for a client with type 1 diabetes who exhibits confusion, light-headedness, and aberrant behavior. The client is conscious. The nurse should first administer:
15 to 20 g of a fast-acting carbohydrate such as orange juice.\ This client is experiencing hypoglycemia. Because the client is conscious, the nurse should first administer a fast-acting carbohydrate, such as orange juice, hard candy, or honey. If the client has lost consciousness, the nurse should administer I.M. or subcutaneous glucagon or an I.V. bolus of dextrose 50%. The nurse shouldn't administer insulin to a client who's hypoglycemic; this action will further compromise the client's condition.
A nurse knows to assess a patient with type 1 diabetes for postprandial hyperglycemia. The nurse knows that glycosuria is present when the serum glucose level exceeds:
180 mg/dL Glycosuria occurs when the renal threshold for sugar exceeds 180 mg/dL. Glycosuria leads to an excessive loss of water and electrolytes (osmotic diuresis).
When the dawn phenomenon occurs, the patient has relatively normal blood glucose until approximate what time of day?
3 AM During the dawn phenomenon, the patient has a relatively normal blood glucose level until about 3 AM, when the level begins to rise.
Glycosylated hemoglobin reflects blood glucose concentrations over which period of time?
3 months Glycosylated hemoglobin is a blood test that reflects average blood glucose concentrations over a period of 3 months.
What is the duration of regular insulin?
4 to 6 hours The duration of regular insulin is 4 to 6 hours; 3 to 5 hours is the duration for rapid-acting insulin such as Novolog. The duration of NPH insulin is 12 to 16 hours. The duration of Lantus insulin is 24 hours.
Glucose range (fasting)
70-110 mg/dL
What is a Biguanide?
A HYPOGLYCEMIC AGENT A Biguanide is a class of oral medications used primarily to treat type 2 diabetes. The most well-known and widely used drug in this class is metformin. How Biguanides Work Biguanides, specifically metformin, help control blood sugar levels by: Reducing Liver Glucose Production: Metformin decreases the amount of glucose produced by the liver, which is a significant source of blood sugar between meals. Increasing Insulin Sensitivity: It improves the body's sensitivity to insulin, allowing cells to take up glucose more effectively from the bloodstream. Decreasing Intestinal Absorption of Glucose: Metformin also reduces the amount of glucose absorbed from food in the intestines.
What is a SGL-2 inhibitor?
A SGLT-2 inhibitor (Sodium-Glucose Co-Transporter 2 inhibitor) is a class of medication primarily used to treat type 2 diabetes. These drugs work by inhibiting the SGLT-2 protein in the kidneys, which is responsible for reabsorbing glucose from the urine back into the blood. By blocking this protein, SGLT-2 inhibitors cause the body to excrete more glucose through the urine, thereby lowering blood sugar levels.
A nurse educates a group of clients with diabetes mellitus on the prevention of diabetic nephropathy. Which of the following suggestions would be most important?
Control blood glucose levels. Controlling blood glucose levels and any hypertension can prevent or delay the development of diabetic nephropathy.
A client with a serum glucose level of 618 mg/dl is admitted to the facility. He's awake and oriented, has hot dry skin, and has the following vital signs: temperature of 100.6° F (38.1° C), heart rate of 116 beats/minute, and blood pressure of 108/70 mm Hg. Based on these assessment findings, which nursing diagnosis takes highest priority?
Deficient fluid volume related to osmotic diuresis A serum glucose level of 618 mg/dl indicates hyperglycemia, which causes polyuria and fluid volume deficit, making Deficient fluid volume related to osmotic diuresis the highest priority. In this client, tachycardia is more likely to result from fluid volume deficit than from decreased cardiac output because his blood pressure is normal. Although the client's serum glucose is elevated, food isn't a priority because fluids and insulin should be administered to lower the serum glucose level. Therefore, a diagnosis of Imbalanced nutrition: Less than body requirements isn't appropriate. A temperature of 100.6° F isn't life-threatening, eliminating Ineffective thermoregulation as the top priority.
The nurse is caring for a client receiving insulin isophane suspension (NPH) at breakfast. What is an important dietary consideration for the nurse to keep in mind?
Encourage midday snack. Because NPH is an intermediate-acting insulin that peaks in approximately 4 to 10 hours, a midday snack should be included in daily calorie intake to avoid hypoglycemia. NPH insulin has no immediate effects. Carbohydrates are distributed throughout the meal plan of diabetics to avoid highs and lows. Delaying dinner meal is not indicated with NPH insulin use.
Which assessment finding is most important in determining nursing care for a client with diabetes mellitus?
Fruity breath The rising ketones and acetone in the blood can lead to acidosis and be detected as a fruity odor on the breath. Ketoacidosis needs to be treated to prevent further complications such as Kussmaul respirations (fast, labored breathing) and renal shutdown. A blood sugar of 170 mg/dL is not ideal but will not result in glycosuria and/or trigger the classic symptoms of diabetes mellitus. Cloudy urine may indicate a UTI.
A nurse is teaching a client with type 1 diabetes how to treat adverse reactions to insulin. To reverse hypoglycemia, the client ideally should ingest an oral carbohydrate. However, this treatment isn't always possible or safe. Therefore, the nurse should advise the client to keep which alternate treatment on hand?
Glucagon During a hypoglycemic reaction, a layperson may administer glucagon, an antihypoglycemic agent, to raise the blood glucose level quickly in a client who can't ingest an oral carbohydrate.
A nurse is inspecting the feet of a client with diabetes and finds a tack sticking in the sole of one foot. The client denies feeling anything unusual in the foot. Which is the best rationale for this finding?
High blood sugar decreases blood circulation to nerves. Diabetic neuropathy results from poor glucose control and decreased blood circulation to nerve tissues. The lack of sensitivity increases the potential for soft tissue injury without awareness. Autonomic neuropathy is a complication of diabetes mellitus but not significant with peripheral injuries. Motor neuropathy does occur with poor glucose control but not specific to this injury. Nephropathy is a common complication that directly affects the kidneys.
Which is the best nursing explanation for the symptom of polyuria in a client with diabetes mellitus?
High sugar pulls fluid into the bloodstream, which results in more urine production. The hypertonicity from concentrated amounts of glucose in the blood pulls fluid into the vascular system, resulting in polyuria. The urinary frequency triggers the thirst response, which then results in polydipsia.
An older adult patient is in the hospital being treated for sepsis related to a urinary tract infection. The patient has started to have an altered sense of awareness, profound dehydration, and hypotension. What does the nurse suspect the patient is experiencing?
Hyperglycemic hyperosmolar syndrome Hyperglycemic hyperosmolar syndrome (HHS) occurs most often in older people (50 to 70 years of age) who have no known history of diabetes or who have type 2 diabetes (Reynolds, 2012). The clinical picture of HHS is one of hypotension, profound dehydration (dry mucous membranes, poor skin turgor), tachycardia, and variable neurologic signs (e.g., alteration of consciousness, seizures, hemiparesis).
When the nurse is caring for a patient with type 1 diabetes, what clinical manifestation would be a priority to closely monitor?
Hypoglycemia The therapeutic goal for diabetes management is to achieve normal blood glucose levels (euglycemia) without hypoglycemia while maintaining a high quality of life.
Which combination of adverse effects should a nurse monitor for when administering IV insulin to a client with diabetic ketoacidosis?
Hypokalemia and hypoglycemia Blood glucose needs to be monitored in clients receiving IV insulin because of the risk of hyperglycemia or hypoglycemia. Hypoglycemia might occur if too much insulin is administered. Hypokalemia, not hyperkalemia, might occur because I.V. insulin forces potassium into cells, thereby lowering the plasma level of potassium.
A nurse is assessing a client who is receiving total parenteral nutrition (TPN). Which finding suggests that the client has developed hyperglycemia?
Increased urine output Glucose supplies most of the calories in TPN; if the glucose infusion rate exceeds the client's rate of glucose metabolism, hyperglycemia arises. When the renal threshold for glucose reabsorption is exceeded, osmotic diuresis occurs, causing an increased urine output. A decreased appetite and diaphoresis suggest hypoglycemia, not hyperglycemia.
The client who is managing diabetes through diet and insulin control asks the nurse why exercise is important. Which is the best response by the nurse to support adding exercise to the daily routine?
Increases ability for glucose to get into the cell and lowers blood sugar Exercise increases trans membrane glucose transporter levels in the skeletal muscles. This allows the glucose to leave the blood and enter into the cells where it can be used as fuel. Exercise can provide an overall feeling of well-being but is not the primary purpose of including in the daily routine of diabetic clients. Exercise does not stimulate the pancreas to produce more cells. Exercise can promote weight loss and decrease risk of insulin resistance but not the primary reason for adding to daily routine.
A young adult client with type 1 diabetes does not want to have to self-administer insulin injections several times a day. Which medication approach would the nurse recommend that best controls the condition and meets the client's needs?
Insulin pump The insulin pump most closely mimics regular pancreas function and increases meal and exercise flexibility. The use of the pump would meet the client's needs of not wanting to self-administer several injections of insulin every day. With one injection per day, there is difficulty controlling fasting blood glucose if the type of insulin does not last. The client could also develop afternoon hypoglycemia if the single dose is increased in order to control the morning fasting glucose level. Two injections per day might meet the client's needs of minimal self-injections; however, for this regimen, there needs to be a fixed schedule of meals and exercise and it is difficult to adjust the dose if premixed insulin is used. Self-administering insulin before each meal will not meet the client's needs since this requires more injections than any other regimen.
NPH is an example of which type of insulin?
Intermediate-acting
The nurse is describing the action of insulin in the body to a client newly diagnosed with type 1 diabetes. Which of the following would the nurse explain as being the primary action?
It carries glucose into body cells. Insulin carries glucose into body cells as their preferred source of energy. Besides, it promotes the liver's storage of glucose as glycogen and inhibits the breakdown of glycogen back into glucose. Insulin does not aid in gluconeogenesis but inhibits the breakdown of glycogen back into glucose. Insulin does not have an effect on the intestinal absorption of glucose.
The nurse is describing the action of insulin in the body to a client newly diagnosed with type 1 diabetes. Which of the following would the nurse explain as being the primary action?
It enhances the transport of glucose across the cell membrane. Insulin carries glucose into body cells as their preferred source of energy. Besides, it promotes the liver's storage of glucose as glycogen and inhibits the breakdown of glycogen back into glucose. Insulin does not aid in gluconeogenesis but inhibits the breakdown of glycogen back into glucose.
A patient is diagnosed with type 1 diabetes. What clinical characteristics does the nurse expect to see in this patient?
Ketosis-prone Little or no endogenous insulin Younger than 30 years of age Type I diabetes mellitus is associated with the following characteristics: onset any age, but usually young (<30 y); usually thin at diagnosis, recent weight loss; etiology includes genetic, immunologic, and environmental factors (e.g., virus); often have islet cell antibodies; often have antibodies to insulin even before insulin treatment; little or no endogenous insulin; need exogenous insulin to preserve life; and ketosis prone when insulin absent
Which type of insulin acts most quickly?
Lispro The onset of action of rapid-acting lispro is within 10 to 15 minutes. The onset of action of short-acting regular insulin is 30 minutes to 1 hour. The onset of action of intermediate-acting NPH insulin is 3 to 4 hours. The onset of action of very long-acting glargine is ~6 hours.
A client with diabetes is receiving an oral anti diabetic agent that acts to help the tissues use available insulin more efficiently. Which of the following agents would the nurse expect to administer?
Metformin Metformin is a biguanide and, along with the thiazolidinediones (rosiglitazone and pioglitazone), are categorized as insulin sensitizers; they help tissues use available insulin more efficiently. Glyburide and glipizide, which are sulfonylureas, and repaglinide, a meglitinide, are described as being insulin releasers because they stimulate the pancreas to secrete more insulin.
The nurse is preparing to administer intermediate-acting insulin to a patient with diabetes. Which insulin will the nurse administer?
NPH Intermediate-acting insulins are called NPH insulin (neutral protamine Hagedorn) or Lente insulin. Lispro (Humalog) is rapid acting, Iletin II is short acting, and glargine (Lantus) is very long acting.
A patient who is diagnosed with type 1 diabetes would be expected to:
Need exogenous insulin. Type 1 diabetes is characterized by the destruction of pancreatic beta cells that require exogenous insulin.
A nurse expects to find which signs and symptoms in a client experiencing hypoglycemia?
Nervousness, diaphoresis, and confusion Signs and symptoms associated with hypoglycemia include nervousness, diaphoresis, weakness, light-headedness, confusion, paresthesia, irritability, headache, hunger, tachycardia, and changes in speech, hearing, or vision. If untreated, signs and symptoms may progress to unconsciousness, seizures, coma, and death. Polydipsia, polyuria, and polyphagia are symptoms associated with hyperglycemia.
A nurse is teaching a diabetic support group about the causes of type 1 diabetes. The teaching is determined to be effective when the group is able to attribute which factor as a cause of type 1 diabetes?
Presence of autoantibodies against islet cells There is evidence of an autoimmune response in type 1 diabetes. This is an abnormal response in which antibodies are directed against normal tissues of the body, responding to these tissues as if they were foreign. Autoantibodies against islet cells and against endogenous (internal) insulin have been detected in people at the time of diagnosis and even several years before the development of clinical signs of type 1 diabetes.
Which clinical characteristic is associated with type 1 diabetes (previously referred to as insulin-dependent diabetes mellitus)?
Presence of islet cell antibodies Individuals with type 1 diabetes often have islet cell antibodies and are usually thin or demonstrate recent weight loss at the time of diagnosis. These individuals are prone to experiencing ketosis when insulin is absent and require exogenous insulin to preserve life.
A client who was diagnosed with type 1 diabetes 14 years ago is admitted to the medical-surgical unit with abdominal pain. On admission, the client's blood glucose level is 470 mg/dl. Which finding is most likely to accompany this blood glucose level?
Rapid, thready pulse This client's abnormally high blood glucose level indicates hyperglycemia, which typically causes polyuria, polyphagia, and polydipsia. Because polyuria leads to fluid loss, the nurse should expect to assess signs of deficient fluid volume, such as a rapid, thready pulse; decreased blood pressure; and rapid respirations. Cool, moist skin and arm and leg trembling are associated with hypoglycemia. Rapid respirations — not slow, shallow ones — are associated with hyperglycemia.
Lispro (Humalog) is an example of which type of insulin?
Rapid-acting Humalog is a rapid-acting insulin. NPH is an intermediate-acting insulin. A short-acting insulin is Humulin-R. An example of a long-acting insulin is Glargine (Lantus).
The nurse is explaining glycosylated hemoglobin testing to a diabetic client. Which of the following provides the best reason for this order?
Reflects the amount of glucose stored in hemoglobin over past several months.
The nurse is administering an insulin drip to a patient in ketoacidosis. What insulin does the nurse know is the only one that can be used intravenously?
Regular Short-acting insulins are called regular insulin (marked R on the bottle). Regular insulin is a clear solution and is usually administered 20 to 30 minutes before a meal, either alone or in combination with a longer-acting insulin. Regular insulin is the only insulin approved for IV use.
The client with diabetes asks the nurse why shoes and socks are removed at each office visit. The nurse gives which assessment finding as the explanation for the inspection of feet?
Sensory neuropathy Neuropathy results from poor glucose control and decreased circulation to nerve tissues. Neuropathy involving sensory nerves located in the periphery can lead to lack of sensitivity, which increases the potential for soft tissue injury without client awareness. The client's feet are inspected on each visit to ensure no injury or pressure has occurred.
A client with diabetes mellitus has a prescription for 5 units of U-100 regular insulin and 25 units of U-100 isophane insulin suspension (NPH) to be taken before breakfast. At about 4:30 p.m., the client experiences headache, sweating, tremor, pallor, and nervousness. What is the most probable cause of these signs and symptoms?
Serum glucose level of 52 mg/dl Headache, sweating, tremor, pallor, and nervousness typically result from hypoglycemia, an insulin reaction in which serum glucose level drops below 70 mg/dl. Hypoglycemia may occur 4 to 18 hours after administration of isophane insulin suspension or insulin zinc suspension (Lente), which are intermediate-acting insulins. Although hypoglycemia may occur at any time, it usually precedes meals. Hyperglycemia, in which serum glucose level is above 180 mg/dl, causes such early manifestations as fatigue, malaise, drowsiness, polyuria, and polydipsia. A serum calcium level of 8.9 mg/dl or 10.2 mg/dl is within normal range and wouldn't cause the client's symptoms.
Laboratory studies indicate a client's blood glucose level is 185 mg/dl. Two hours have passed since the client ate breakfast. Which test would yield the most conclusive diagnostic information about the client's glucose use?
Serum glycosylated hemoglobin (Hb A1c) Hb A1c is the most reliable indicator of glucose use because it reflects blood glucose levels for the prior 3 months. Although a fasting blood glucose test and a 6-hour glucose tolerance test yield information about a client's use of glucose, the results are influenced by such factors as whether the client recently ate breakfast. Presence of ketones in the urine also provides information about glucose use but is limited in its diagnostic significance.
A client with a tentative diagnosis of hyperosmolar hyperglycemic nonketotic syndrome (HHNS) has a history of type 2 diabetes that is being controlled with an oral diabetic agent, tolazamide. Which laboratory test is the most important for confirming this disorder?
Serum osmolarity Serum osmolarity is the most important test for confirming HHNS; it's also used to guide treatment strategies and determine evaluation criteria. A client with HHNS typically has a serum osmolarity of more than 350 mOsm/L. Serum potassium, serum sodium, and ABG values are also measured, but they aren't as important as serum osmolarity for confirming a diagnosis of HHNS. A client with HHNS typically has hypernatremia and osmotic diuresis. ABG values reveal acidosis, and the potassium level is variable.
A client with status asthmaticus requires endotracheal intubation and mechanical ventilation. Twenty-four hours after intubation, the client is started on the insulin infusion protocol. The nurse must monitor the client's blood glucose levels hourly and watch for which early signs and symptoms associated with hypoglycemia?
Sweating, tremors, and tachycardia Sweating, tremors, and tachycardia, thirst, and anxiety are early signs of hypoglycemia. Dry skin, bradycardia, and somnolence are signs and symptoms associated with hypothyroidism. Polyuria, polydipsia, and polyphagia are signs and symptoms of diabetes mellitus.
Insulin is a hormone secreted by the Islets of Langerhans and is essential for the metabolism of carbohydrates, fats, and protein. The nurse understands the physiologic importance of gluconeogenesis, which refers to the:
Synthesis of glucose from noncarbohydrate sources. Gluconeogenesis refers to the making of glucose from noncarbohydrates. This occurs mainly in the liver. Its purpose is to maintain the glucose level in the blood to meet the body's demands.
Which of the following factors would a nurse identify as a most likely cause of diabetic ketoacidosis (DKA) in a client with diabetes?
The client has eaten and has not taken or received insulin. If the client has eaten and has not taken or received insulin, DKA is more likely to develop. Hypoglycemia is more likely to develop if the client has not consumed food and continues to take insulin or oral antidiabetic medications, if the client has not consumed sufficient calories, or if client has been exercising more than usual.
Which may be a potential cause of hypoglycemia in the client diagnosed with diabetes mellitus?
The client has not eaten but continues to take insulin or oral antidiabetic medications.
Which may be a potential cause of hypoglycemia in the client diagnosed with diabetes mellitus?
The client has not eaten but continues to take insulin or oral antidiabetic medications. Hypoglycemia occurs when a client with diabetes is not eating and continues to take insulin or oral antidiabetic medications. Hypoglycemia does not occur when the client has not been compliant with the prescribed treatment regimen. If the client has eaten and has not taken or received insulin, diabetic ketoacidosis is more likely to develop.
A client is diagnosed with diabetes mellitus. The client reports visiting the gym regularly and is a vegetarian. Which of the following factors is important to consider when the nurse assesses the client?
The client's consumption of carbohydrates While assessing a client, it is important to ask about consumption of carbohydrates due to the client's high blood sugar. Although other factors such as the client's mental and emotional status, history of tests involving iodine, and exercise routine can be part of data collection, they are not the priority when assessing a client with high blood sugar.
The pancreas continues to release a small amount of basal insulin overnight, while a person is sleeping. The nurse knows that if the body needs more sugar:
The pancreatic hormone glucagon will stimulate the liver to release stored glucose. When sugar levels are low, glucagon promotes hyperglycemia by stimulating the release of stored glucose. Glycogenolysis and gluconeogenesis will both be increased. Insulin secretion would promote hypoglycemia.
A nurse educator been invited to local seniors center to discuss health-maintaining strategies for older adults. The nurse addresses the subject of diabetes mellitus, its symptoms, and consequences. What should the educator teach the participants about type 1 diabetes?
The participants are unlikely to develop a new onset of type 1 diabetes. Type 1 diabetes usually (but not always) develops in people younger than 20. In older adults, an onset of type 2 is far more common. A significant number of older adults develops type 2 diabetes.
A nurse is preparing to administer two types of insulin to a client with diabetes mellitus. What is the correct procedure for preparing this medication?
The short-acting insulin is withdrawn before the intermediate-acting insulin. When combining two types of insulin in the same syringe, the short-acting regular insulin is withdrawn into the syringe first and the intermediate-acting insulin is added next. This practice is referred to as "clear to cloudy."
A client with diabetes mellitus develops sinusitis and otitis media accompanied by a temperature of 100.8° F (38.2° C). What effect do these findings have on his need for insulin?
They increase the need for insulin. Insulin requirements increase in response to growth, pregnancy, increased food intake, stress, surgery, infection, illness, increased insulin antibodies, and some medications. Insulin requirements are decreased by hypothyroidism, decreased food intake, exercise, and some medications.
A client receives a daily injection of glargine insulin at 7:00 a.m. When should the nurse monitor this client for a hypoglycemic reaction?
This insulin has no peak action and does not cause a hypoglycemic reaction. "Peakless" basal or very long-acting insulins are approved by the U.S. Food and Drug Administration for use as a basal insulin; that is, the insulin is absorbed very slowly over 24 hours and can be given once a day. It has is no peak action.
The nurse is teaching a client about self-administration of insulin and about mixing regular and neutral protamine Hagedorn (NPH) insulin. Which information is important to include in the teaching plan?
When mixing insulin, the regular insulin is drawn up into the syringe first. When rapid-acting or short-acting insulins are to be given simultaneously with longer-acting insulins, they are usually mixed together in the same syringe; the longer-acting insulins must be mixed thoroughly before being drawn into the syringe. The American Diabetic Association recommends that the regular insulin be drawn up first. The most important issues are that patients (1) are consistent in technique, so the wrong dose is not drawn in error or the wrong type of insulin, and (2) do not inject one type of insulin into the bottle containing a different type of insulin. Injecting cloudy insulin into a vial of clear insulin contaminates the entire vial of clear insulin and alters its action.
Hyperglycemic Hyperosmolar Syndrome (HHS)
a metabolic disorder of type 2 diabetes resulting from a relative insulin deficiency initiated by an illness that raises the demand for insulin
postprandial hypoglycemia
an unusual drop in blood glucose that follows a meal and is accompanied by symptoms such as anxiety, rapid heartbeat, and sweating; also called reactive hypoglycemia.
what is a Glitazone?
antidiabetic; thiazolidinedione A glitazone, also known as a thiazolidinedione (TZD), is a class of medications used to treat type 2 diabetes. These drugs work by improving insulin sensitivity, which helps the body use insulin more effectively to lower blood sugar levels.
During a class on exercise for clients with diabetes mellitus, a client asks the nurse educator how often to exercise. To meet the goals of planned exercise, the nurse educator should advise the client to exercise:
at least three times per week. Clients with diabetes must exercise at least three times per week to meet the goals of planned exercise — lowering the blood glucose level, reducing or maintaining the proper weight, increasing the serum high-density lipoprotein level, decreasing serum triglyceride levels, reducing blood pressure, and minimizing stress. Exercising once per week wouldn't achieve these goals. Exercising more than three times per week, although beneficial, would exceed the minimum requirement.
A nurse is explaining the action of insulin to a client with diabetes mellitus. During client teaching, the nurse reviews the process of insulin secretion in the body. The nurse is correct when she states that insulin is secreted from the:
beta cells of the pancreas. The beta cells of the pancreas secrete insulin. The alpha cells of the pancreas secrete glucagon, which raises the blood glucose level.
polyphagia
excessive hunger
ketoacidosis
excessive production of ketones, making the blood acidic
polydipsia
excessive thirst
polyuria
excessive urination
Hyperglycemia S/S
frequent urination, deep rapid labored respirations, thirst, hunger, dry mucous membranes, weakness, malaise, rapid, weak pulse, hypotension, soft eyeballs
A client with a 30-year history of type 2 diabetes is having an annual physical and blood work. Which test result would the physician be most concerned with when monitoring the client's treatment compliance?
glycosylated hemoglobin Once a client with diabetes receives a treatment regimen to follow, the physician can assess the effectiveness of treatment and the client's compliance by obtaining a hemoglobin A1c test. The results of this test reflect the amount of glucose that is stored in the hemoglobin molecule during its life span of 120 days. Normally, the level of glycosylated hemoglobin is less than 7%. Amounts of 8% or greater indicate that control of the client's blood glucose level has been inadequate during the previous 2 to 3 months.
A client tells the nurse that she has been working hard for the past 3 months to control her type 2 diabetes with diet and exercise. To determine the effectiveness of the client's efforts, the nurse should check:
glycosylated hemoglobin level. Because some of the glucose in the bloodstream attaches to some of the hemoglobin and stays attached during the 120-day life span of red blood cells, glycosylated hemoglobin levels provide information about blood glucose levels during the previous 3 months. Fasting blood glucose and urine glucose levels give information only about glucose levels at the point in time when they were obtained. Serum fructosamine levels provide information about blood glucose control over the past 2 to 3 weeks.
hyperglycemic
high blood sugar (<110mg/dL)
Which is a characteristic of type 2 diabetes?
insulin resistance Type 2 diabetes is characterized by either a decrease in endogenous insulin or an increase accompanied by insulin resistance. Type 1 diabetes is characterized by production of little or no insulin; the client with type 1 diabetes is ketosis-prone when insulin is absent and often has islet cell antibodies.
A client with a history of type 1 diabetes is demonstrating fast, deep, labored breathing and has fruity odored breath. What could be the cause of the client's current serious condition?
ketoacidosis Kussmaul respirations (fast, deep, labored breathing) are common in ketoacidosis. Acetone, which is volatile, can be detected on the breath by its characteristic fruity odor. If treatment is not initiated, the outcome of ketoacidosis is circulatory collapse, renal shutdown, and death. Ketoacidosis is more common in people with diabetes who no longer produce insulin, such as those with type 1 diabetes. People with type 2 diabetes are more likely to develop hyperosmolar hyperglycemic nonketotic syndrome because with limited insulin, they can use enough glucose to prevent ketosis but not enough to maintain a normal blood glucose level.
hypoglycemic
low blood sugar (>70mg/dL)
Hypoglycemia S/S
nausea, nervousness, & irritability, sweatinesss w/ pale skin.diaphoresis, pale cool skin, irritability, normal/shallow respirations, tachycardia and palpitations, strange or unusual respirations. slurred speeech, headache and blurred vision, decreasing loc, seizures leading to coma, change in emotional behavior,difficulty thinking.
osmotic diuresis
osmotic diuresis happens when there is an excess of certain solutes, like glucose or mannitol, in the kidneys. These solutes create an osmotic gradient, pulling more water into the urine and leading to increased urine output. This condition is often seen in people with uncontrolled diabetes, where high blood sugar levels lead to the excretion of glucose in the urine, causing more water to follow and resulting in frequent urination.
Which of the following medications is considered a glitazone?
pioglitazone Pioglitazone and rosiglitazone are classified as a glitazone or thiazolidinedione. Metformin and metformin with glyburide are classified as biguanides. Dapagliflozin is classified as a sodium-glucose co-transporter 2 (SGL-2) inhibitor.
Ketoacidosis S/S
polydipsia, polyuria, fruity breath, dry mucous membranes, kussmual RR (deep labored breathing), type 1 diabtic, nausea
A client has been recently diagnosed with type 2 diabetes, and reports continued weight loss despite increased hunger and food consumption. This condition is called:
polyphagia While the needed glucose is being wasted, the body's requirement for fuel continues. The person with diabetes feels hungry and eats more (polyphagia). Despite eating more, he or she loses weight as the body uses fat and protein to substitute for glucose.
glycosuria
presence of glucose in the urine
diaphoresis
profuse sweating
A nurse is assigned to care for a postoperative client with diabetes mellitus. During the assessment interview, the client reports that he's impotent and says he's concerned about the effect on his marriage. In planning this client's care, the most appropriate intervention would be to:
suggest referral to a sex counselor or other appropriate professional. The nurse should refer this client to a sex counselor or other professional. Making appropriate referrals is a valid part of planning the client's care. The nurse doesn't normally provide sex counseling.
Gluconeogenesis
the making of glucose from a noncarbohydrate source such as amino acids or glycerol
A child is brought into the emergency department with vomiting, drowsiness, and blowing respirations. The child's parent reports that the symptoms have been progressing throughout the day. The nurse suspects diabetic ketoacidosis (DKA). Which action should the nurse take first in the management of DKA?
Begin fluid replacements. Management of DKA is aimed at correcting dehydration, electrolyte loss, and acidosis before correcting the hyperglycemia with insulin.
A client with diabetic ketoacidosis was admitted to the intensive care unit 4 hours ago and has these laboratory results: blood glucose level 450 mg/dl, serum potassium level 2.5 mEq/L, serum sodium level 140 mEq/L, and urine specific gravity 1.025. The client has two IV lines in place with normal saline solution infusing through both. Over the past 4 hours, his total urine output has been 50 ml. Which physician order should the nurse question?
Change the second IV solution to dextrose 5% in water. The nurse should question the physician's order to change the second IV solution to dextrose 5% in water. The client should receive normal saline solution through the second IV site until his blood glucose level reaches 250 mg/dl. The client should receive a fluid bolus of 500 ml of normal saline solution. The client's urine output is low and his specific gravity is high, which reveals dehydration. The nurse should expect to hold the insulin infusion for 30 minutes until the potassium replacement has been initiated. Insulin administration causes potassium to enter the cells, which further lowers the serum potassium level. Further lowering the serum potassium level places the client at risk for life-threatening cardiac arrhythmias.
