N212-Diabetic DrugsUnit 2 test

What are the five types of insulin? What are examples of rapid-acting insulins? Humalog (lispro), Apidra (glulisine), and Novolog (aspart) are rapid-acting insulin analogs. What are rapid-acting insulin? Rapid-acting insulins are analogs of regular insulin. An analog is a chemical structure very similar to another but differing in one component. The amino acid sequences of these analogs are nearly identical to human insulin. They differ in the positioning of certain proteins, which allow them to enter the bloodstream rapidly— within 15 min of subcutaneous injection. This closely mimics the body's own insulin response and allows greater flexibility in eating schedules for diabetic patients. When do rapid-acting insulins enter the bloodstream? Within 15 minutes of subcutaneous injection. Why is the risk of hypolgycemic episodes lessened in patients taking rapid-acting insulin? Because these insulins leave the bloodstream quickly, the risk of hypoglycemic episodes several hours after the meal is lessened. What is the peak time for rapid-acting insulins? What is the duration? The peak time for rapid-acting insulins is 1-2 hr and the duration is 3-4 hr. What rapid-acting insulins can be given intravenously? Both insulin aspart and insulin glulisine can be given intravenously in selected situations under medical supervision. What are examples of short-acting insulin? Regular insulin is short-acting insulin and is available commercially as Humulin R or Novolin R. What is the onset of regular insulin (short-acting)? What is it's peak activity and duration? The onset of regular insulin is 0.5-1 hr; its peak activity occurs 2-4 hr after subcutaneous injection and its duration of action is 5-7 hr. This time/action profile makes rigid meal scheduling necessary, as the patient must estimate that a meal will occur within 45 min of injection. True or False Regular insulin can be given intravenously. True What are intermediate-acting insulins? Intermediate-acting insulin contains protamine, which delays onset, peak, and duration of action to provide basal insulin coverage. Basal insulins are given to control blood glucose levels throughout the day when not eating. What are examples of intermediate-acting insulins? Commercially, intermediate-acting insulins are available as Humulin N or Novolin N. (The "N" stands for NPH.) When does action occur with intermediate-acting insulins? When does peak activity occur? Duration? Action starts between 2 and 4 hr after injecting. Peak activity occurs between 4 and 10 hr. Duration of action lasts 10-16 hr. True or False The nurse should throw away Humulin N if it is cloudy. False The addition of protamine causes the cloudy appearance of intermediate-acting insulins and results in the formulation being a suspension rather than a solution. This is why these insulins must be gently mixed before administering. Can intermediate-acting insulins be mixed? Yes. Intermediate-acting insulins can be mixed with short- or rapid-acting insulins to provide both basal and bolus coverage. Long-acting insulins have the most _______ onset and the _______ duration of all insulins. delayed longest What are examples of long-acting insulins? Products include Lantus (insulin glargine) and Levemir (insulin detemir). Are peaks prominent in long-acting insulins? No Upgrade to remove ads Only $1/month Why doesn't insulin glargine have real peak action? In fact, insulin glargine has no real peak action because it forms slowly dissolving crystals in the subcutaneous tissue. What is the onset of action of insulin glargine? What about full activity? The onset of action of insulin glargine is 3-4 hr after subcutaneous injection. Full activity occurs within 4 to 5 hr and remains constant for 24 hr Can long-acting insulins be mixed or diluted with other insulins or solutions? No. Even though insulin glargine and insulin detemir are clear solutions, neither can be diluted or mixed with any other insulin or solution. Mixing insulin glargine or insulin detemir with other insulin products can alter the onset of action and time to peak effect. If bolus insulin is to be given at the same time as insulin glargine or insulin detemir, two separate syringes and injection sites must be used. What are combination insulins? Various combinations of premixed insulins are available, containing fixed proportions of two different insulins. What insulins are usually mixed together in combination insulin? Usually a short- and an intermediate-acting insulin. Typically the intermediate-acting insulin makes up 70-75% of the mixture, with rapid- or short- acting insulin making up the remainder. What are examples of combination insulin? Brand names of these products include Humulin 70/30 (70% NPH, 30% regular), Humalog Mix 75/25 (75% insulin lispro protamine suspension and 25% insulin lispro), Humalog Mix 50/50 (50% insulin lispro protamine suspension and 50% insulin lispro), and Novolin 70/30 (70% NPH, 30% regular), or Novolog 70/30 (70% insulin aspart protamine suspension and 30% insulin aspart). What is the indication of insulin? Control of hyperglycemia in patients with type 1 or type 2 diabetes mellitus. What is the action of insulin? What is the therapeutic effect? Lower blood glucose by: stimulating glucose uptake in skeletal muscle and fat, inhibiting hepatic glucose production. Other actions: inhibition of lipolysis and proteolysis, enhanced protein synthesis. Therapeutic Effects: Control of hyperglycemia in diabetic patients. Where is insulin metabolized? Metabolized by liver, spleen, kidney, and muscle. When is insulin contraindicated? Contraindicated in: Hypoglycemia; Allergy or hypersensitivity to a particular type of insulin, preservatives, or other additives When should insulin be used cautiously? Stress and infection (may temporarily increase insulin requirements); Renal/hepatic impairment (may decrease insulin requirements); Concomitant use with pioglitazone or rosiglitazone (increase risk of fluid retention and worsening HF); OB: Pregnancy may temporarily increase insulin requirements What are side effects/adverse reactions of insulin? Endo: HYPOGLYCEMIA. Local: erythema, lipodystrophy, pruritis, swelling. Misc: allergic reactions including ANAPHYLAXIS. What are drug-drug interactions of insulin? Drug-Drug: Beta blockers, clonidine, and reserpine may mask some of the signs and symptoms of hypoglycemia. Corticosteroids, thyroid supplements, estrogens, isoniazid, niacin, phenothiazines, and rifampin may increase insulin requirements. Alcohol, ACE inhibitors, MAO inhibitors, octreotide, oral hypoglycemic agents, and salicylates, may decreases insulin requirements. Concurrent use with pioglitazone or rosiglitazone may increase risk of fluid retention and worsening HF. What are drug-natural product interaction? Drug-Natural Products: Glucosamine may worsen blood glucose control. Fenugreek, chromium, and coenzyme Q-10 may produce additive hypoglycemic effects. What is the common dose range of insulin: Subcut (Adults and Children): 0.5-1 unit/kg/day. Adolescents during rapid growth—0.8-1.2 units/kg/day. What should patients be assessed for when taking insulin? Assess for symptoms of hypoglycemia and hyperglycemia periodically during therapy. What are symptoms of hypoglycemia? Anxiety; restlessness; tingling in hands, feet, lips, or tongue; chills; cold sweats; confusion; cool, pale skin; difficulty in concentration; drowsiness; excessive hunger; headache; irritability; nightmares or trouble sleeping; nausea; nervousness; tachycardia; tremor; weakness; unsteady gait What are symptoms of hyperglycemia? Confusion, drowsiness; flushed, dry skin; fruit-like breath odor; rapid, deep breathing, polyuria; loss of appetite; nausea; vomiting; unusual thirst Why should a patient's weight be monitored periodically? Changes in weight may necessitate changes in insulin dose Would insulin potentially cause an increase or decrease in serum phosphate, magnesium, and potassium levels? Decrease How often should blood glucose and A1C be monitored? Monitor blood glucose every 6 hr during therapy, more frequently in ketoacidosis and times of stress. Hemoglobin A1C may also be monitored every 3-6 mo to determine effectiveness. How is severe hypoglycemia treated? Severe hypoglycemia is a life-threatening emergency; treatment consists of IV glucose, glucagon, or epinephrine. Is insulin a high-alert drug? Yes Why is insulin a high-alert drug? Insulin-related medication errors have resulted in patient harm and death. Clarify ambiguous orders; do not accept orders using the abbreviation "u" for units, (can be misread as a zero or the numeral 4; has resulted in tenfold overdoses). Can the nurse use any syringe to draw up insulin? No. Use only insulin syringes to draw up dose. The unit markings on the insulin syringe must match the insulin's units/mL. True or False NPH insulins should be used in the management of ketoacidosis. FALSE NPH insulins should not be used in the management of ketoacidosis. Should insulin injection sites be rotated? Yes Where should insulin be injected? Administer into abdominal wall, thigh, or upper arm subcutaneously. Can regular insulin be used IV? May be administered IV undiluted directly into vein or through Y-site. Rate: Administer up to 50 units over 1 min. For continuous infusions, what can regular insulin be diluted in? May be diluted in 0.9% NaCl using polyvinyl chloride infusion bags. Concentration: 0.1 unit/mL to 1 unit/mL in infusion systems with the infusion fluids. Rate: Rate should be ordered by health care professional, and infusion placed on an IV pump for accurate administration. Rate of administration should be decreased when serum glucose level reaches 250 mg/dL. A health-care provider prescribes for an 8-year-old child to receive 1 unit of aspart insulin for every 15 grams of carbohydrates consumed at mealtime. Additionally, the client is to receive insulin per the sliding scale insulin as noted below. The 8-year-old child's fingerstick blood glucose before breakfast is 82, and the child ate 30 grams of carbohydrates at breakfast. Based on this information and the sliding scale below, the nurse should administer ______ unit(s) to the child. 70-79.................. -2 and call 80-89.................. -1 90-180................. 0 181-200............... 1 201-250............... 2 251-300............... 3 More than 300... Call ANSWER: 1 One unit of insulin aspart should be administered. The client should receive 2 units for the 30 grams of carbohydrates (CHO) minus 1 unit for the blood glucose of 82 mg/dL, for a total of 1 unit. ➧ Test-taking Tip: Carefully read what the question is asking. Be sure to note both the insulin "coverage dose" for the carbohydrate intake and the insulin "correction dose" for the blood sugar Use the following sliding scale to determine the amount of insulin to give your patient: No coverage: Glucose less than 150 2 units: Glucose 150-200 4 units: Glucose 201-275 6 units: Glucose 276-350 8 units: Glucose 351-400 Glucose over 400 NHO stat 1. How much insulin would you give if you had a glucose of 140? 2. How much insulin would you give if the glucose was 280? 1. No coverage since the glucose is less than 150 2. 6 units using an insulin syringe. A nurse is evaluating teaching for a client who has diabetes and is beginning insulin therapy using an insulin pen. Which behavior should best indicate to a nurse that teaching about the insulin therapy was effective? 1. The nurse showing the client a video that explains how to use the insulin pen 2. The client reading a handout that describes the different types of insulin and insulin pens 3. The nurse demonstrating the correct procedure for preparing the insulin pen for administration 4. The client preparing the insulin pen and self-injecting correctly on the first attempt ANSWER: 4 The client correctly demonstrating withdrawing and administering insulin suggests that the teaching about medication was effective. Options 1 and 3 are teaching strategies. Option 2 does not demonstrate that learning has occurred. The client correctly demonstrating preparing the insulin pen and administering the insulin suggests that the teaching about insulin therapy was effective. Options 1 and 3 are nursing interventions using various teaching strategies. Option 2 is a client action but it does not demonstrate that learning has occurred. ➧ Test-taking Tip: Focus on what the question is asking, "indicates teaching . . . was effective" and the nursing process step of evaluation. Options that include nursing interventions should be eliminated as well as any options with client behaviors that do not demonstrate that learning has occurred. A client diagnosed with hyperglycemia is receiving a continuous intravenous (IV) insulin drip. Blood glucose measures are being taken every 1 to 2 hours. A nurse checks the client's blood glucose, and the reading is 32 mg/dL. The client, who was previously alert, is now lethargic and does not respond to questions. The nurse administers 25 mL of D50W per protocol. The client begins to respond. Which additional risk-management action should be taken by the nurse? 1. Continue the insulin drip 2. Report the event to the nurse manager 3. Recheck the blood glucose measure in 1 hour 4. Administer a second dose of 25 mL of D50W ANSWER: 2 Safety events must be reported to the nurse manager. Risk management seeks to identify and eliminate potential safety hazards. The monitoring and medication protocol may need revision based on changes in the client's status and correlating blood glucose results. Reporting the client's hypoglycemia to the nurse manager will result in the monitoring of patterns and trends, and possibly regulatory reporting. Some states require reporting of hypoglycemia that leads to client injury or death. To continue the insulin drip would result in client injury. Waiting 1 hour is too long to determine if the client is still hypoglycemic. A second dose of D50W should not be given without first assessing the client's response and taking another blood glucose measurement. ➧ Test-taking Tip:The key words "risk management action" include appropriate follow-up and reporting. Eliminate options that pertain only to the client. A nurse, who is working the evening shift, is planning to administer insulin subcutaneously to a hospitalized child. Which statement made by the nurse to the mother would be inappropriate? 1. "It is okay for your child to say 'ouch,' cry, or even scream when receiving an injection." 2. "I can give the injection while your child is sleeping; then the injection won't be noticed." 3. "I will apply lidocaine/prilocaine (EMLA®) cream, a topical analgesic, 1 hour before the injection to reduce pain." 4. "The child will need to be lying, but after the injection you can hold and comfort your child." ANSWER: 2 Injections should never be administered to a sleeping child because the injection is painful and the child will wake up and be terrified. Giving approval for the child to vent his or her feelings provides the child with a better sense of control. EMLA® cream can reduce the pain with insertion, but pain may still be felt as the medication is injected. The child can be lying flat during the injection. ➧ Test-taking Tip:The key word is "inappropriate." A nurse instructs a client on safe disposal of insulin syringes and needles when at home. Which statement by the client indicates that additional teaching is needed? 1. "After I draw up my insulin, I scoop the cap to cover it while I cleanse my skin." 2. "I have a needle destruction device that breaks the needles from the syringes so that others won't get stuck by the needles." 3. "I plan to use this plastic milk container to discard my used needles and syringes and take it to the clinic for disposal." 4. "Because the needles are capped, the syringes are safe to dispose of with my household trash." ANSWER: 4 Used needles and syringes should not be placed in the household trash because of the risk of needlestick injuries to waste management personnel. Scooping the cap to cover the needle protects others from needlestick injuries. The U.S. Environmental Protection Agency (2004) recommends that at-home syringes and needles be disposed of through use of needle destruction devices, sharps mail-back programs, community drop-off programs, or household hazardous waste facilities. ➧ Test-taking Tip:The key phrase is "additional teaching is needed." Select the statement that is incorrect. A nurse is planning the care of a 2-hour-old infant at 38 weeks gestation whose mother has type 1 diabetes mellitus. The nurse writes the following NANDA diagnosis: "Altered Nutrition: less than body requirements" and appropriately adds which "related to" statement? 1. Decreased amounts of red blood cells secondary to low erythropoietin levels 2. Decreased amounts of total body fat secondary to decreased growth hormone 3. Increased glucose metabolism secondary to hyperinsulinemia 4. Increased amounts of body water ANSWER: 3 While in utero, the fetus of a diabetic mother is exposed to high levels of maternal glucose. Hyperplasia of the fetal pancreas occurs resulting in hyperinsulinemia. When the fetus is born, the glucose supply from the mother is disrupted and the neonate's blood sugar falls rapidly in response to the corresponding high levels of circulating insulin. The infant of an insulin-dependent mother (IDM) has increased amounts of red blood cells (RBCs) because hemoglobin A1c binds to oxygen, decreasing the oxygen available to the fetal tissues. This tissue hypoxia stimulates increased erythropoietin production, which stimulates RBC production. The IDM has increased amounts of body fat as a result of hyperinsulinemia, which converts glucose to adipose tissue and stimulates production of pituitary growth hormone. IDMs have decreased total body water, particularly in the extracellular spaces. ➧ Test-taking Tip: Recall the physiology of diabetes and the adaptations made by the IDM A clinic nurse is evaluating a client with type 1 diabeteswho intends to enroll in a tennis class. Which statement made by the client indicates that the client understands the effects of exercise on insulin demand? 1. "I will carry a high-fat, high-calorie food, such as a cookie." 2. "I will administer 1 unit of lispro insulin prior to playing tennis." 3. "I will eat a 15-gram carbohydrate snack before playing tennis." 4. "I will decrease the meal prior to the class by 15-grams of carbohydrates." ANSWER: 3 Excessive exercise without sufficient carbohydrates can result in unexpected hypoglycemia. The food should be a simple sugar food because the fat content of a high-fat food will delay the absorption of the glucose in the food. Taking insulin or decreasing the carbohydrate intake prior to activity will lower the blood glucose level such that hypoglycemia can occur. ➧ Test-taking Tip: Recall that type 1 diabetes mellitus requires daily insulin administration and that activity increases energy expenditure and the demand for glucose. Two hours after taking a regular morning dose of Insulin Regular (Humulin R®), a client presents to a clinic with diaphoresis, tremors, palpitations, and tachycardia. Which nursing action is most appropriate for this client? 1. Check pulse oximetry and administer oxygen at 2 L per nasal cannula. 2. Administer a baby aspirin, one sublingual nitroglycerin tablet, and obtain an electrocardiogram (ECG). 3. Check blood glucose level and provide carbohydrates if less than 70 mg/dL (3.8 mmol/L). 4. Check vital signs and administer atenolol (Tenormin®) 25 mg orally if heart rate is greater than 120 beats per minute. ANSWER: 3 Humulin R is regular insulin that peaks in 2 to 4 hours after administration. The client's symptoms suggest hypoglycemia, so a blood glucose level should be checked. The symptoms do not suggest a respiratory problem (option 1). Though diaphoresis, palpitations, and tachycardia are symptoms of both hypoglycemia and cardiac problems, the client had taken insulin 2 hours earlier. Treating the low blood sugar first will likely resolve the client's symptoms. ➧ Test-taking Tip: Focus on the effects of Humulin R and the client's symptoms A nurse working on a telemetry unit is planning to complete noon assessments for four assigned clients with type 1 diabetes mellitus. All of the clients received subcutaneous insulin aspart (NovoLog®) at 0800 hours. In which order should the nurse assess the clients? Place each answer option into the correct order. _____ A 60-year-old client who is nauseous and has just vomited for the second time _____ A 45-year-old client who is dyspneic and has chest pressure and new onset atrial fibrillation _____ A 75-year-old client with a fingerstick blood glucose level of 300 mg/dL _____ A 50-year-old client with a fingerstick blood glucose level of 70 mg/dL ANSWER: 2, 1, 3, 4 First, the nurse should assess the client with new onset atrial fibrillation and dyspnea. Diabetes increases the risk of coronary artery disease and myocardial infarction. Next, assess the client who just vomited. The client with a 300 mg/dL blood glucose level should then be assessed. This blood glucose level is not immediately life-threatening, but needs to be lowered as soon as possible. The client with the blood glucose level of 70 mg/dL can be assessed last because this is a normal blood glucose level. ➧ Test-taking Tip: Use the ABC's (airway, breathing, circulation) to establish the priority client. Then, look at the information provided for each client to determine the next priority. Consider that all clients received insulin at 0800 hours. A nurse is caring for a client with type 2 diabetes on a telemetry unit. The client is scheduled for cardiac rehabilitation exercises (cardiac rehab). The nurse notes that the client's blood glucose level is 300 mg/dL and the urine is positive for ketones. Which nursing action should be included in the nurse's plan of care? 1. Send the client to cardiac rehab because exercise will lower the client's blood glucose level. 2. Administer insulin and then send the client to cardiac rehab with a 15-gram carbohydrate snack. 3. Delay the cardiac rehab because blood glucose levels will decrease too much with exercise. 4. Cancel the cardiac rehab because blood glucose levels will increase further with exercise. ANSWER: 4 Exercising with blood glucose levels exceeding 250 mg/dL and ketonuria increases the secretion of glucagon, growth hormone, and catecholamines, causing the liver to release more glucose. Exercise in the presence of hyperglycemia does not lower the blood glucose level (options 1 and 3). Administering insulin may be an option, but the blood glucose level should be known before sending the client to cardiac rehab (option 2). ➧ Test-taking Tip: Think about the physiological effects of stress on blood glucose levels. Then eliminate options 1 and 3 because these are incorrect. Of the remaining two options, decide which action is safest for the client. A nurse administers 15 units of glargine (Lantus®) insulin at 2100 hours to a Hispanic client when the client's fingerstick blood glucose reading was 110 mg/dL. At 2300 hours, a nursing assistant reports to the nurse that an evening snack was not given because the client was sleeping. Which instruction by the nurse is most appropriate? 1. "You will need to wake the client to check the blood glucose and then give a snack. All diabetics get a snack at bedtime." 2. "It is not necessary for this client to have a snack because glargine insulin is absorbed very slowly over 24 hours and doesn't have a peak." 3. "The next time the client wakes up, check a blood glucose level and then give a snack." 4. "I will need to notify the physician because a snack at this time will affect the client's blood glucose level ANSWER: 2 The onset of glargine is 1 hour, it has no peak, and it lasts for 24 hours. Glargine lowers the blood glucose by increasing transport into cells and promoting the conversion of glucose to glycogen. Because it is peakless, a bedtime snack is unnecessary. Options 1 and 3 are unnecessary and option 4 is incorrect. Glargine is administered once daily, the same time each day, to maintain relatively constant concentrations over 24 hours. ➧ Test-taking Tip: Apply knowledge of the action of glargine insulin. A client diagnosed with diabetes mellitus is on an insulin infusion drip. The insulin bag indicates there are 100 units of insulin in 1,000 milliliters (mL) of normal saline. Based on the client's blood glucose reading, the client should receive 1.5 units per hour. To ensure that the client receives 1.5 units per hour, the nurse should set the pump at ______ mL/hr. ANSWER: 15 100 units : 1,000 mL :: 1.5 units : X mL 100X = 1,500 X = 15 ➧ Test-taking Tip: Use a drug calculation formula and the on-screen calculator and double-check the answer if it seems unusually large. A nurse is teaching a client who has been newly diagnosed with type 2 diabetes mellitus (DM). Which teaching point should the nurse emphasize? 1. Use the arm when self-administering NPH insulin. 2. Exercise for 30 minutes daily, preferably after a meal. 3. Consume 30% of the daily calorie intake from protein foods. 4. Eat a 30-gram carbohydrate snack prior to strenuous activity. ANSWER: 2 Exercise increases insulin receptor sites in the tissue and can have a direct effect on lowering blood glucose levels. Exercise also contributes to weight loss, which also decreases insulin resistance. Usually type 2 DM is controlled with oral hypoglycemic agents. If insulin is needed, sites should be rotated. For those with DM, protein should contribute less than 10% of the total energy consumed. Strenuous activity can be perceived by the body as a stressor, causing a release of counterregulatory hormones that subsequently increases blood glucose. Hyperglycemia can result from the combination of strenuous activity and extra carbohydrates. ➧ Test-taking Tip:The key terms are "type 2" and "emphasize." Apply knowledge of type 2 DM and eliminate options 1, 3, and 4 because type 2 diabetics will produce some insulin, and often weight reduction, calorie reduction, and exercise will help to normalize glucose levels. A nurse is evaluating a client's outcome. The client's nursing care plan includes the nursing diagnosis of fluid volume deficit related to hyperosmolar hyperglycemic nonketotic syndrome (HHNS) secondary to severe hyperglycemia. The nurse knows that the client has a positive outcome when which serum laboratory value has decreased to a normal range? 1. Glucose 2. Sodium 3. Osmolality 4. Potassium ANSWER: 3 Extreme hyperglycemia produces severe osmotic diuresis; loss of sodium, potassium, and phosphorous; and profound dehydration. Consequently, hyperosmolality occurs. A normalizing of the serum osmolality indicates that the fluid volume deficit is resolving. A decrease in serum glucose indicates that the hyperglycemia is resolving, but not the fluid volume deficit. Serum sodium and potassium values should increase, not decrease, with treatment. ➧ Test-taking Tip: Focus on the issue: deficient fluid volume. A client with type 1 diabetes mellitus is scheduled for a total hip replacement. In reviewing the client's orders the evening prior to surgery, a nurse notes that the physician did not write an order to change the client's daily insulin dose. Which nursing action is most appropriate? 1. Notify the physician who wrote the insulin order in the client's medical record. 2. Write an order to decrease the morning insulin dose by one-half of the prescribed morning dose. 3. Do nothing because the physician would want the client to receive the usual insulin dose prior to surgery. 4. Inform the day shift nurse to check the client's fingerstick glucose before surgery and hold the morning dose of insulin. ANSWER: 1 Because the client will be NPO (nothing per mouth) for surgery, the nurse must ensure that the usual insulin dosage has been changed to prevent hypoglycemia. The change may include eliminating the rapid-acting insulin and giving a decreased amount of intermediate-acting NPH or Lente insulin. A registered nurse is unable to prescribe medications. The nurse could write the order based on standing orders, but this is not noted in the option. Doing nothing could cause a hypoglycemic reaction because the client will be NPO for surgery. Holding the morning dose of insulin can cause hyperglycemia leading to diabetic ketoacidosis. Even without food, glucose levels increase from hepatic glucose production. Clients with type 1 diabetes require insulin 24 hours a day. ➧ Test-taking Tip: Note the key words "most appropriate." Eliminate options 2 and 4 knowing that the nurse should neither write an order to change the dose nor hold the dose. Both require a physician order. Next, look at options 1 and 3. Eliminate option 3, recalling the effects of insulin when the client is NPO. A nurse administers a usual morning dose of 4 units of regular insulin and 8 units of NPH insulin at 7:30 a.m. to a client with a blood glucose level of 110 mg/dL. Which statements regarding the client's insulin are correct? 1. The onset of the regular insulin will be at 7:45 a.m. and the peak at 1:00 p.m. 2. The onset of the regular insulin will be at 8:00 a.m. and the peak at 10:00 a.m. 3. The onset of the NPH insulin will be at 8:00 a.m. and the peak at 10:00 a.m. 4. The onset of the NPH insulin will be at 12:30 p.m. and the peak at 11:30 p.m. ANSWER: 2 The onset of regular insulin (short-acting) is one-half to 1 hour, and the peak is 2 to 3 hours. The onset of NPH insulin (intermediate acting) is 2 to 4 hours, and the peak is 4 to 12 hours. All other options have incorrect medication onset and peak times. ➧ Test-taking Tip: Apply knowledge of insulin onset and peak times. A home-health nurse is planning the first home visit for a 60-year-old Hispanic client newly diagnosed with type 2 diabetes mellitus. The client has been instructed to take 70/30 combination insulin in the morning and at suppertime. Which interventions should be included in the client's plan of care? SELECT ALL THAT APPLY. 1. Instruct the client to inspect the feet daily. 2. Ensure that the client eats a bedtime snack. 3. Assess the client's ability to read small print. 4. Teach the client how to perform a hemoglobin A1c test. 5. Instruct the client on storing prefilled syringes in the refrigerator. 6. Teach the client to take one unit of 70/30 insulin after eating a snack. ANSWER: 1, 2, 3, 5 Diabetes, diabetic complications, and increased mortality have been reported to occur at a higher rate in Hispanics compared with non-Hispanic whites of the same age. Therefore, careful daily skin assessment is necessary. Neuropathy, peripheral vascular disease, and immunocompromise can result in diabetic foot ulcer and complications. The 70/30 insulin is a combination of NPH and regular insulin. The NPH insulin will peak 4 to 12 hours after administration. A bedtime snack will cover the insulin peak to prevent hypoglycemia. Magnifying devices are available if the client is unable to read small print to prevent dosing errors. Syringes may be prefilled but should be stored in the refrigerator with the needle up. Blood is drawn in the laboratory to check the A1c. Only short-acting (regular) or rapid-acting insulin (aspart or lispro), not 70/30 insulin, would be administered to cover for additional carbohydrates if the client were on a carbohydrate-counting regimen with insulin coverage. This would be prescribed by the physician. ➧ Test-taking Tip: Focus on the situation, an older adult client with type 2 diabetes taking 70/30 insulin. Apply knowledge of care of the diabetic client and insulin types to select the correct options. Which physician's order should the nurse question for a newly admitted client diagnosed with diabetic ketoacidosis (DKA)? 1. D5W at 125 mL per hour 2. KCL 10 mEq in 100 mL NaCl IV now 3. Stat arterial blood gases. Administer sodium bicarbonate if pH is less than 7.0. 4. Regular insulin infusion per protocol adjusting dose based on hourly glucose levels ANSWER: 1 In DKA, the blood glucose level is above 300 mg/dL. Additional glucose will only increase the glucose level. Initially 0.45% or 0.9% sodium chloride (NaCl) is administered for fluid resuscitation. Glucose may be added when blood glucose levels approach 250 mg/dL. Insulin will drive potassium into the cells, so potassium chloride (KCL) is administered to prevent life-threatening hypokalemia. Normal pH is 7.35 to 7.45. Sodium bicarbonate will reverse the severe acidosis. Intravenous (IV) insulin will correct the hyperglycemia and hyperketonemia. Tight glucose control can be maintained by hourly glucose checks and adjusting the insulin infusion dose. ➧ Test-taking Tip: Note the key word "question." Select the option that would not be included in the treatment of the client with DKA. Which instructions should the nurse provide to a client regarding diabetes management during stress or illness? SELECT ALL THAT APPLY. 1. Notify the health-care provider if unable to keep fluids or foods down. 2. Test fingerstick glucose levels and urine ketones daily and keep a record. 3. Continue to take oral hypoglycemic medications and/or insulin as prescribed. 4. Supplement food intake with carbohydrate-containing fluids, such as juices or soups. 5. When on an oral agent, administer insulin in addition to the oral agent during the illness. 6. A minor illness, such as the flu, usually does not affect the blood glucose and insulin needs. ANSWER: 1, 3 An acute or minor illness can evoke a counterregulatory hormone response resulting in hyperglycemia, thus the client should continue medications as prescribed. If the client is unable to eat due to nausea and vomiting, dehydration can occur from hyperglycemia and the lack of fluid intake. Blood glucose should be checked every 4 hours when ill and the ketones tested every 3 to 4 hours if the glucose is greater than 240 mg/dL. The client should supplement the diet with carbohydrate-containing fluids only if eating less than normal due to the illness. Insulin may or may not be necessary; it is based on the client's blood glucose level. ➧ Test-taking Tip: Focus on the counterregulatory hormone response during an illness that causes hyperglycemia. A client calls a clinic to renew the prescription for insulin being administered subcutaneously via an insulin pump. Which insulin type, if prescribed by a physician, should the nurse question? 1. Insulin lispro (Humolog®) 2. Insulin aspart (Novolog®) 3. Insulin glulisine (Apidra®) 4. Insulin glargine (Lantus®) ANSWER: 4 Glargine is long-duration insulin not suited to delivery by an infusion pump; the order should be questioned. Four types of insulin may be delivered through an insulin pump: regular, lispro, aspart, and glulisine. These are short-duration and short or rapid-acting types of insulin that can be administered at a basal rate for continuous infusion at a slow but steady rate. The pump can also be triggered manually to provide a bolus dose to accommodate insulin needs to match the caloric contents of a meal. ➧ Test-taking Tip: Recall that only short-duration and short- or rapid-acting types of insulin can be administered through an insulin pump. Thus, select the option with a long-duration insulin. A 12-year-old child's medication regimen for treating type 1 diabetes mellitus is changed from administering NPH and rapid-acting insulin to a basal-bolus insulin regimen. To achieve tight glucose control and for therapy to be effective, the nurse should instruct that the child and/or parent to: SELECT ALL THAT APPLY. 1. administer a once daily dose of a long-acting insulin such as glargine (Lantus®). 2. administer rapid-acting insulin such as aspart (NovoLog®) with each meal and snack based on the carbohydrate grams consumed. 3. administer extra rapid-acting insulin when the amount of the child's daily exercise increases. 4. consistently count the amount of carbohydrates the child consumes throughout the day. 5. monitor the child's blood glucose four to eight times a day. 6. monitor the child's blood glucose at midnight and 3 a.m. once a week. ANSWER: 1, 2, 4, 5, 6 With basal-bolus insulin therapy, basal insulin is administered once a day using glargine, and then a bolus of rapid-acting insulin is administered with each meal and snack based on the number of carbohydrates eaten and the child's blood glucose level. Depending on the amounts of snacks eaten, blood glucose could be monitored up to eight times a day, and the child may get six to seven injections a day. Because of the potential for hypoglycemia at night, the child's blood glucose should be monitored at midnight and 3 a.m. once a week. Exercise increases the need for carbohydrates and not insulin. ➧ Test-taking Tip: Read each option carefully. The duration of glargine insulin is 24 hours. The onset of aspart insulin is 5 to 10 minutes. Recall that aspart administration can be either subcutaneously or through an insulin infusion pump. A 9-year-old child with a history of type 1 diabetes mellitus for the past 6 years is admitted with a diagnosis of diabetic ketoacidosis (DKA). In preparing for the child's arrival to the nursing unit, the nurse should prepare to: 1. add sodium bicarbonate to the current IV fluids. 2. add potassium chloride to the current IV fluids. 3. use either 0.9% or 0.45% saline for the base IV fluid. 4. administer insulin by subcutaneous injection ANSWER: 3 Both water and sodium are depleted in DKA, thus the child will require intravenous saline. Research has shown no benefit to giving sodium bicarbonate to children with DKA to reverse metabolic acidosis. Potassium is added only after laboratory studies have confirmed that the plasma potassium is low. Usually there is not a drop in plasma potassium. Insulin is always given IV in DKA for rapid effect and close monitoring. Insulin onset by subcutaneous route is 15 to 30 minutes and can cause hypoglycemia from potential excessive dosing when attempting to reduce the hyperglycemia. ➧ Test-taking Tip: Recall that high blood glucose levels causes osmotic diuresis and the loss of fluids. DKA is a life-threatening condition, and the nurse needs to be ready to act when the child is admitted. The parents of a 7-year-old child diagnosed with type 1 diabetes mellitus are planning to drive 1,200 miles for a vacation at the beach. They question the nurse about insulin storage for the trip. Which response by the nurse is most accurate? 1. "Because insulin must be refrigerated, you will need to obtain the medication from a pharmacy at your destination." 2. "Freeze the insulin before you leave home and take it in a cooler; it should be thawed by the time you get to the beach." 3. "Keep the insulin in a cooler with an ice pack and out of direct heat and sunlight for the trip. Store unopened insulin in the refrigerator at your destination." 4. "Because it is illegal to transport needles and syringes across most state lines, you will need to obtain a prescription from your doctor and purchase the insulin and the syringes at your destination." ANSWER: 3 Because insulin should be kept out of direct sunlight and extreme heat, it should be transported in a cooler with an ice pack. Insulin is destroyed when frozen. Although it is not illegal to transport needles and syringes, the child should have a prescription to identify the medication and justify the syringes. The prescription also provides a means to obtain additional supplies if needed. ➧ Test-taking Tip: Focus on what the question is asking: insulin storage. Eliminate options 1 and 4 because these responses do not address insulin storage. Decide the best option, 2 or 3. Note that option 3 is more complete, thus eliminate option 2. An adolescent client is taught how to use a continuous subcutaneous insulin infusion pump for tight glucose control of type 1 diabetes mellitus. Which statement by the client indicates the need for additional teaching? 1. "I can put in the number of carbohydrates that I consume, and the insulin pump will calculate the bolus insulin dose that I will receive." 2. "I must still check my blood glucose levels with meals and snacks and calculate the amount of carbohydrates I consume to ensure I get the correct bolus dose of insulin." 3. "As my blood glucose control improves with the use of the insulin pump, I should see a drop in the weight that I have gained." 4. "Every 2 to 4 days, I will need to change the syringe, catheter, and site moving the site away at least 1 inch from the last site." ANSWER: 3 Weight gain, and not weight loss, commonly occurs as blood glucose control improves. Newer pumps calculate bolus insulin dose to the carbohydrates consumed. Monitoring blood glucose levels and carbohydrates consumed is still necessary with an insulin pump. About every 2 to 4 days when a syringe is empty, a new syringe and tubing is attached to the pump along with a new skin setup. The site is also changed to prevent lipoatrophy. ➧ Test-taking Tip:The key phrase "need for additional teaching" indicates that this is a false-response question. Select the option that is incorrect. Note that options 1, 2, and 4 relate to the pump operation, whereas option 3 is different. Often the option that is different is the answer. The mother of a 12-year-old child diagnosed with type 1 diabetes mellitus asks a nurse what changes in the daily routine should be made during attendance at summer camp. The child will be at camp for 4 weeks. Which is the best response by the nurse? 1. "The child will have an increased need for insulin due to the high carbohydrate content of camp food." 2. "The child's food intake should be decreased by 10% while the insulin should be increased by 10%." 3. "The child's food intake should be increased as activity increases; monitor blood glucose levels three to four times a day to evaluate results." 4. "The child's insulin injection should be given before every meal and snack to ensure that the food being consumed at camp can be utilized by the body." ANSWER: 3 Increases in muscle activity promote a more efficient utilization of glucose. School-aged children are more physically active in the summer months than during the school year. An increase of insulin with an increase in physical activity and/or a decrease in food consumption will result in profound hypoglycemia. Giving regular insulin before every meal and snack is an option for older individuals who are usually engaged in regular, high-intensity physical activity; it would not be recommended for a 12-year-old child attending 4 weeks of camp. ➧ Test-taking Tip: Knowledge of the physiological mechanism of insulin utilization by the body is needed, as well as the relationship of food to insulin needs and the metabolic needs of a 12-year-old child. A nurse completes teaching insulin administration to the parent of a toddler newly diagnosed with type 1 diabetes mellitus. The nurse concludes that the teaching was successful when the parent states: 1. "NPH insulin (Humulin N®) is only given at night immediately before the bedtime snack." 2. "It is okay to use only the buttocks for the insulin injections until the child is older." 3. "Insulin lispro (Humalog®) acts within 15 minutes and peaks 30 to 90 minutes after injection." 4. "Insulin detemir (Levenir®) can be added to the insulin lispro (Humalog®) pen to reduce the number of injections." ANSWER: 3 Lispro is rapid-acting insulin that peaks in 30 to 90 minutes and may last as long as 5 hours in the blood. NPH insulin can be given in the morning, but there is better glucose control if given at night. NPH peaks in 4 to 14 hours, so there is no need to make sure food is available immediately after administration. Insulin injections should always be rotated to prevent subcutaneous tissue damage from giving the injections in the same location. Detemir is long-acting and lispro is rapid-acting insulin. An insulin pen uses pre-filled, multiple-use insulin cartridges; adding other types of insulins should not be attempted. An adult client experiencing diabetic ketoacidosis has been admitted to an emergency department. Which interventions should a nurse initiate immediately? SELECT ALL THAT APPLY. 1. Administer oxygen. 2. Administer D5W with 0.9% NaCl solution after establishing an intravenous (IV) access. 3. Initiate a regular insulin infusion. 4. Determine the time and amount of the last insulin injection. 5. Administer potassium and magnesium to correct electrolyte imbalances. 6. Assess the client's breath for the presence of ketones. ANSWER: 1, 3, 4 Diabetic ketoacidosis is characterized by hyperglycemia (usually above 300 mg/dL), ketosis, acidosis, and dehydration. Airway management with oxygen administration is necessary. Regular insulin infusion is initiated to lower the client's blood glucose levels. Determining the time and amount of the last insulin injection is needed to ascertain the initial starting dose of the insulin infusion. The initial IV solution is 0.9% NaCl. Once glucose levels approach 250 mg/dL (13.9 mmol/L), 5% dextrose is added. Although electrolyte imbalances occur due to the loss of electrolytes from hyperglycemic diuresis, laboratory assessment of the client's serum values should be completed first. Assessing the breath odor is an assessment not an intervention. ➧ Test-taking Tip: Note the key words, "interventions" and "immediately." Eliminate options that are assessments and those that should not be initiated immediately.

Rapid-acting, short-acting, intermediate-acting, long-acting,and combination insulin's.

cholinergic agonists inhibit the action of the enzyme cholinesterase:

(ChE) by forming a chemical complex, thus permitting acetylcholine to persist and attach to the receptor. Indirect acting

Cholinergic receptor:

Stimulate smooth muscle and slow the heart rate. Muscarinic receptor - Affect the skeletal muscles. - Nicotinic (neuromuscular) receptor

__ cholinergic agonists act on receptors to activate"

a tissue response/Direct acting on receptors to activate a tissue response.

wo groups of drugs that affect the parasympathetic nervous system: __ cholinesterase inhibitors are potent agents because of their long lasting effect; used to produce pupillary construction. Irreversible Anticholinergics The major body tissues and organs affected by the anticholinergic group of drugs are the: • Heart • Respiratory tract • GI tract • Bladder • Eyes • Exocrine glands Anticholinergics The major response to anticholinergics are: • Decrease GI motility • Decrease salivation • Dilation of pupils (mydriasis) • Increase HR An __ can act as an antidote to the toxicity caused by cholinesterase inhibitors and organophosphate ingestion. anticholinergic Anticholinergics Atropine sulfate, a classic anticholinergic is primarily used for: 1. Decreased salivation 2. Increase HR Anticholinergics Synthetic anticholinergic drugs are also used to as antispasmodics to treat __ and __. example: Peptic ulcers, intestinal spasticity propantheline bromide (Pro-Banthine) Anticholinergics The common side effects of atropine and atropine like drugs include: • Dry mouth • Decreased perspiration • Blurred vision • Tachycardia • Constipation • Urinary retention Anticholinergics Other side effects of atropine: • Nausea • Headache • Dry skin • Abdominal dissension • Hypotension or hypertension • Impotence • Photophobia • Coma Anticholinergics Used to suppress tremors and muscular rigidity. Antiparkinson-anticholinergic drugs Example antiparkinson drugs: • trihexyphenidyl hydrochloride (Artane) • biperidan (Akineton) • benztropine (Cogentin) An example of an anticholinergic classified as an antihistamine for motion sickness is __. scopolamine Other drugs for motionsickess: • dimenhydrinate (Dramamine) • cyclizine (Marzine) • meclizine hydrochloride (Antivert) Because anticholinergic drugs can increase intraocular pressure, they should not be administered to patients diagnosed with __. glaucoma Side effects of antihistamines used as anticholinergics include: • Dry mouth • Visual disturbance • Constipation • Urinary retention • Tachycardia • Hypotension • Skin rash • Muscle weakness • Flushing

Cholinergic agonists (parasympathomimetics) • Anticholinergics (parasympatholytics)

2 types of cholinergic receptors: 2 type of cholinergic inhibitors (anticholinesterase): Reversible and irreversible The major responses of cholinergic agonists are to: • Stimulate bladder and GI tone • Constrict pupils • Increase neuromuscular transmission Other effects of cholinergic agonists: • Decrease HR and BP • Increase salivary, GI, and Bronchial secretions Example of direct acting cholinergic agonists: • bethanechol chloride (Urecholine) • metoclopramide HCL (Reglan) • Pilocarpine Direct acting cholinergic agonists Used to increase micturition: bethanechol chloride (Urecholine) Direct acting cholinergic agonists Used to treat gastroesophageal reflux disease (GERD) metoclopramide HCL (Reglan) Direct acting cholinergic agonists Used to constrict the pupils of the eyes, thus opening the canal of Schlemm to promote drainage of aqueous humor. Treats glaucoma. Pilocarpine Direct acting cholinergic agonists __ is a side effect of a cholinergic agonists such as bethanechol. Orthostatic hypotension Direct acting cholinergic agonists Give cholinergic agonists __ hr before or __ hr after meals. 1, 2 Direct acting cholinergic agonists Have IV __ available as an antidote for cholinergic overdose. atropine sulfate (0.6mg to 1.2mg) Indirect acting cholinergic agonists The function of the enzyme cholinesterase is to break down into __ and __. choline, acetic acid The primary use of reversible cholinesterase inhibitors is to treat: • Myasthenia gravis • Alzheimers disease The primary clinical indication for irreversible cholinesterase inhibitors is: glaucoma Reversible cholinesterase inhibitors Are used to: 1. Constrict pupils 2. Increase muscle strength in patients with myasthenia gravis. Example reversible cholinesterase drugs: • neostigmine (Prostigmin) short • pyridostigmine bromide (Mestinon) moderate • ambenomium chloride (Mytelase) long • edrophonium chloride (Tensilon) short Reversible cholinesterase inhibitors __ is used as an antidote for atropine to reverse anticholinergic toxicity. Physostigmine (reversible cholinesterase inhibitor)

• Muscarinic • Nicotinic (neuromuscular)