Pharmacology Chapter 41 Drug Therapy for Diabetes Mellitus
A nurse is providing client education to a 13-year-old girl who was just diagnosed with type 1 diabetes mellitus. Which statement by the client will alert the nurse that special instructions regarding insulin are necessary?
"I am on the middle school track team." Explanation: Because the client is on the track team, she will have increased exercise at various times that will require increased insulin and special instructions related to hypoglycemia that may come hours after she has ceased exercising. Walking two blocks every day and walking up stairs would not be considered increased physical exercise and would not be a factor. Wanting to have her mother administer the insulin is not uncommon for this age client, and the nurse would normally instruct both the mother and the daughter in the administration of the drug.
A young man has been diagnosed with type 2 diabetes and has been prescribed glyburide. Which statement suggests that the nurse should perform further health education?
"I'll plan to take my glyburide each night before I go to bed." Explanation: Glyburide is normally taken in the morning, before breakfast. No drug cures diabetes; the goal of therapy is the maintenance of safe blood glucose levels. The client should check before taking other drugs and should indeed be aware of the risk of hypoglycemia.
The nurse is discussing diabetes with a group of individuals who are at risk for the disease. Which statement by a participant indicates an understanding of the role of insulin in the disease?
"Insulin assists glucose molecules to enter the cells of muscle and fat tissues." Explanation: Insulin appears to activate a process that helps glucose molecules enter the cells of striated muscle and adipose tissue. It also stimulates the synthesis of glycogen by the liver, promotes protein synthesis, and helps the body store fat by preventing its breakdown for energy.
What instructions would be important to give to a 50-year-old client with type 2 diabetes who has been switched from glyburide (DiaBeta), a sulfonylurea, to repaglinide, a meglitinide?
"It stimulates insulin production, so you need to eat soon after taking the medication." Explanation: Glyburide's onset of action is 2 to 4 hours, and its duration is 24 hours. Repaglinide's onset of action is within 30 minutes, peak is 1 hour, and duration is approximately 3 to 4 hours. Repaglinide is taken 15 to 30 minutes before each meal because it stimulates the pancreas to secrete insulin to correspond to the food intake. If there is no food intake, the person is at risk of hypoglycemia. Glyburide, a sulfonylurea, also stimulates pancreatic cells, but not until 2 to 4 hours after it is taken. Repaglinide is not less potent, it is not more potent, and the two medications are not virtually the same.
A 59-year-old man with type 2 diabetes is prescribed metformin. When the client returns to the clinic, he reports that he has lost 8 pounds in a month. How should the nurse respond?
"Please continue taking the medication and monitoring your weight. This is an expected outcome of this drug therapy." Explanation: The nurse should advise the client to continue therapy as prescribed because weight loss is a beneficial adverse effect for type 2 diabetics. The client need not seek a decrease in dosage or change in medication, nor would discontinuation of the drug be warranted.
What statement would be appropriately included in the teaching concerning type 2 diabetes?
"Regular exercise makes your body better able to use the insulin it produces." Explanation: People who need less than 0.5 units/kg/d may produce some endogenous insulin, or their tissues may be more responsive to insulin because of exercise and good physical conditioning. Exercise is an extremely strong hypoglycemic agent. Diabetics need to check their blood sugar level regardless of whether they are or are not prescribed insulin. The need for insulin injections is determined by the function of the pancreas and its ability to produce sufficient quantities of insulin. It is not correct to assume diet is the only factor in this process. Alcohol should be avoided, and the dosage of oral antidiabetic medication should not be altered without guidance from a health care provider.
What instructions should the nurse give to a client with type 2 diabetes who has been switched from glyburide (DiaBeta) to repaglinide?
"Repaglinide rapidly stimulates insulin production, so you need to eat soon after taking the medication." Explanation: Glyburide is a second-generation sulfonylurea that stimulates insulin release from the beta cells in the pancreas with a 2- to 4-hour onset of action. Repaglinide has an onset of action within 30 minutes with peak effect in 1 hour, and duration of action is approximately 3 to 4 hours. Because repaglinide has a much faster onset of action, it is important the client eats within 15 to 30 minutes after taking the drug to avoid hypoglycemia. Repaglinide is not less potent, it is not more potent, and the two medications are not virtually the same.
The nurse transcribes an order for chlorpropamide (Diabinese). What is an appropriate dosage range for this medication?
100 to 250 mg per day Explanation: The appropriate dosage range for oral chlorpropamide is 100 to 250 mg/d. Tolbutamide is 0.25 to 3 g/d. Glimepiride is 1 to 4 mg/d. Glipizide is taken 5 mg PO daily.
A client who began treatment for type 2 diabetes 8 months ago is now meeting with a diabetic nurse for a scheduled follow-up. How can the nurse best assess the client's glycemic control since beginning treatment?
Assess the most recent hemoglobin A1C levels. Explanation: Health care providers also look at the glycosylated hemoglobin (hemoglobin A1C) levels to assess the effectiveness of treatment. Because glucose stays attached to hemoglobin for the life of the red blood cell, which is about 120 days, the hemoglobin A1C level reflects the average blood glucose level over the past 3 months. Reviewing blood glucose readings, measuring the client's random blood glucose, and dialoguing with the client are all therapeutic strategies, but hemoglobin A1C is most accurate.
A female client is a newly diagnosed diabetic. She is a stay-at-home mother and responsible for meal planning and management of the home. What will the home care nurse teach this client? (Select all that apply.)
Assist the client in making menus that will meet the needs of both the client and the family. Watch the client draw up and administer her insulin. Reinforce instructions on dealing with hypoglycemia. Explanation: The home care nurse would assist the client and family to know how to plan meals that meet the needs of the client and the family. The nurse would also want to assure that the client knows how to administer insulin correctly and would need to make sure that the client understands how to deal with hypoglycemia.
A nurse is caring for a 48-year-old woman who has been hospitalized after injecting the wrong type of insulin. Which sign of hypoglycemia will the nurse be careful to observe for?
Blurred vision Explanation: Blurred or double vision (diplopia), fatigue, trembling, irritability, headache, nausea, numbness, muscle weakness, hunger, tachycardia, sweating, and nervousness are signs of a hypoglycemic reaction. Fruity breath can be an indication of ketoacidosis, and flushing of the face is a sign of hyperglycemia. Dry skin is unrelated to hypoglycemia.
A nurse should take what steps prior to administering insulin glargine (Lantus) to a client? Select all that apply.
Check the expiration date on the vial. Check the health care provider's orders for the type and dosage of insulin. Remove all air bubbles from the syringe barrel. Explanation: Prior to administering insulin glargine (Lantus) to a client, the nurse must complete the following pre-administration steps: carefully check the provider's order for the type and dosage of insulin, check the expiration date on the vial, gently rotate the vial between the palms of the hands, and gently tilt end-to-end before withdrawing the insulin, remove all air bubbles from the syringe barrel, and never mix or dilute insulin glargine (Lantus) with any other insulin or solution because the insulin will not be effective.
A female client visits the health care provider's office after routine labs are drawn. The nurse notes that her A1C is 9. How does the nurse interpret this finding?
Client's average blood glucose is above normal. Explanation: The American Diabetes Association (ADA) suggests a target A1C of less than 7%. A1C should be measured every 3 to 6 months. An A1C of 9 indicates that the client's average blood glucose is consistently above normal.
A client with a recent diagnosis of type 2 diabetes has begun taking metformin. This drug will help the client achieve adequate blood sugar control through which mechanisms? (Select all that apply)
Decreasing glucose production by the liver Improving insulin sensitivity Decreasing glucose absorption in the GI tract Explanation: Metformin decreases hepatic glucose production, decreases intestinal absorption of glucose, and improves insulin sensitivity by increasing peripheral glucose uptake and use in skeletal muscle and adipose tissue through increased transport of glucose across the cell membrane. It does not promote urinary excretion of glucose or bind it to adipose tissue.
A client who is a newly diagnosed diabetic is prescribed glyburide. The nurse caring for this client identifies which occurrence is a classic symptom of hyperglycemia?
Excessive urination Explanation: The classic symptoms of hyperglycemia include excessive urination (polyuria) and excessive thirst (polydipsia) caused by the osmotic pull of glucose. Grand mal seizures and hemiparesis are symptoms of nonketotic hyperglycemia, while tachycardia is a symptom of diabetic ketoacidosis.
Which is the best indicator of overall diabetic control?
Glycosylated hemoglobin levels Explanation: The glycosylated hemoglobin indicates glucose bound to hemoglobin in red blood cells (RBCs) when RBCs are exposed to hyperglycemia. The binding is irreversible and lasts for the lifespan of RBCs (approximately 120 days). The test reflects the average blood sugar level during the previous 2 to 3 months. The goal is usually less than 7% (blood level 0.07). The range for people without diabetes is approximately 4% to 6% (blood level 0.04 to 0.06). Reference:
Clients with type 2 diabetes have nonfunctioning beta pancreatic cells.
False Explanation: Type 2 diabetes reflects an inability to produce enough insulin as needed or a change in insulin receptor sensitivity.
A nurse is caring for a patient who has developed a hypoglycemic reaction. Which intervention should the nurse perform if swallowing and gag reflexes are present in the patient?
Give oral fluids or candy. Explanation: The nurse should administer oral fluids or candy to the hypoglycemic patient with swallowing and gag reflexes. If the patient is unconscious the nurse should administer glucose or glucagon parenterally. The nurse should administer insulin through an insulin pump to special categories of diabetic patients, such as pregnant women with diabetes and renal transplantation. Oral antidiabetic drugs are administered to patients with type 2 diabetes.
A man is brought to the emergency department. He is nonresponsive, and his blood glucose level is 32 mg/dL. Which would the nurse expect to be ordered?
Glucagon Explanation: The client is significantly hypoglycemic and needs emergency treatment. Glucagon would be the agent of choice to raise the client's glucose level because it can be given intravenously and has an onset of approximately 1 minute. Diazoxide can be used to elevate blood glucose levels, but it must be given orally. Lispro and regular insulin would be used to treat hyperglycemia.
Which would a nurse identify as an example of a sulfonylurea?
Glyburide Explanation: Glyburide is an example of a sulfonylurea. Metformin is classified as a biguanide. Acarbose and miglitol are alpha-glucosidase inhibitors.
The nurse is interviewing a client who was diagnosed with type 2 diabetes four months ago. The client does not records glucometer readings but reports no concerns. What laboratory test does the nurse anticipate the health care provider will order for this client?
HbA1c Explanation: The nurse anticipates that the glycosylated hemoglobin (HbA1c) will be ordered for this client because it provides an average of the client's blood glucose level for the last three- to four-month period. It will also tell how well controlled the client's blood glucose is. A stat urine for glucose and an FBG in the AM will only indicate the client's current blood glucose level, not how well it is being controlled. An insulin level will not give the information needed to understand the client's control of blood glucose.
Which of the following are risk factors for type 2 diabetes that a nurse should recognize in a client? Select all that apply:
Impaired glucose tolerance Obesity History of gestational diabetes Explanation: A nurse should be able to identify all the risk factors for type 2 diabetes in a client. These include: obesity, older age, family history of diabetes, history of gestational diabetes, impaired glucose tolerance, minimal or no physical activity, and race/ethnicity (African Americans, Hispanic/Latino Americans, Native Americans, and some Asian Americans).
When describing the effects of incretins on blood glucose control to a group of students, which would an instructor include?
Increases insulin release Explanation: Incretins increase insulin release, decrease glucagon release, slow GI emptying, and stimulate the satiety center. Growth hormone increases protein building.
A nurse at a health care facility is assigned to administer insulin to the patient. Which intervention should the nurse perform before administering each insulin dose?
Inspect the previous injection site for inflammation. Explanation: The nurse should check the previous injection site before administering each insulin dose. The injection sites should be rotated to prevent lipodystrophy. Prefilled syringes should not be kept horizontally; they should be kept in a vertical or oblique position to avoid plugging the needle. The nurse checks for symptoms of myalgia or malaise when administration of metformin leads to lactic acidosis. Insulin should be kept at room temperature for administration. Insulin is refrigerated if it needs to be stored for up to three months for later use.
A client newly diagnosed with type 1 diabetes asks the nurse why the client cannot just take a pill. The nurse would incorporate what knowledge when responding to this client?
Insulin is needed because the beta cells of the pancreas are no longer functioning. Explanation: Insulin is needed in type 1 diabetes because the beta cells of the pancreas are no longer functioning. With type 2 diabetes, insulin is produced, but perhaps not enough to maintain glucose control or the insulin receptors are not sensitive enough to insulin.
After teaching a class about the various drugs used to control blood glucose, the instructor determines that the teaching was successful when the class identifies what as a biguanide?
Metformin Explanation: Metformin is classified as a biguanide. Miglitol is an alpha-glucosidase inhibitor. Tolbutamide is a first generation sulfonylurea. Glipizide is a second generation sulfonylurea.
A nurse is presenting an educational event at a local senior citizens' club about diabetes. What would the nurse tell the attendees at the event about diabetes?
It is a complicated disorder that alters the metabolism of glucose. Explanation: Diabetes is a complicated disorder that alters the metabolism of glucose, fats, and proteins affecting many end organs and causing numerous clinical complications. It is part of the metabolic syndrome, a collection of conditions that predispose to cardiovascular disease.
Lactic acidosis can occur in clients receiving metformin (Glucophage), especially those with renal impairment, which of the following are symptoms of lactic acidosis for which a nurse should monitor a client taking metformin (Glucophage)? Select all that apply:
Malaise Tachypnea Abdominal pain Muscular pain Explanation: Symptoms of lactic acidosis include malaise, abdominal pain, tachypnea, shortness of breath, and muscular pain.
Which would be least appropriate when administering insulin by subcutaneous injection?
Massaging the site after removing the needle Explanation: Gentle pressure should be applied to the injection after the needle is withdrawn. Massaging could contribute to erratic or unpredictable absorption.
The nurse is caring for a client with polycystic ovary syndrome. What antidiabetic drug would the nurse anticipate will be ordered?
Metformin Explanation: Metformin and pioglitazone have proven effective in increasing insulin sensitivity and decreasing androgen and luteinizing hormone levels to break the cycle and allow ovulation to occur if pregnancy is desired. A fertility drug is often used with the antidiabetic agent. Other options are not appropriate because they are not indicated for treating polycystic ovary syndrome.
What antidiabetic agent is approved for the nurse to administer to children 10 years old and older with type 2 diabetes?
Metformin Explanation: Metformin is the only oral antidiabetic drug approved for children. It has established dosage for children 10 years of age and older. With the increasing number of children being diagnosed with type 2 diabetes, the use of other agents in children is being tested. Because metformin is the only drug approved for use with children, pioglitazone, repaglinide, and luraglutide would not be appropriate.
A nurse is caring for a patient with diabetes mellitus who is receiving an oral antidiabetic drug. Which of following ongoing assessments should the nurse perform when caring for this patient?
Observe the patient for hypoglycemic episodes. Explanation: As the ongoing assessment activity, the nurse should observe the patient for hypoglycemic episodes. Documenting family medical history and assessing the patient's skin for ulcers, cuts, and sores on the body is a pre-administration assessment activity performed by the nurse. Lipodystrophy occurs if the sites of insulin injection are not rotated.
The nurse monitoring a client receiving insulin glulisine (Apidra) notices the client has become confused, diaphoretic, and nauseated. The nurse checks the client's blood glucose and it is 60 mg/dL (3.33 mmol/L). Which can a nurse give to treat a client with a hypoglycemic episode? (Select all that apply.)
Orange or other fruit juice Glucose tablets Hard candy Explanation: Methods of terminating a hypoglycemic reaction include the administration of one or more of the following: orange or other fruit juice, hard candy or honey, glucose tablets, glucagon, or glucose 10 percent or 50 percent IV.
A student asks the nursing instructor what insulin has the quickest therapeutic effect once administered. What would be the best response?
Regular (Humulin R) Explanation: Regular insulin has the quickest onset of 30-60 minutes. PZI and ultralente have an onset of 4-8 hours. NPH has an onset of 60-90 minutes.
The nurse is caring for a postoperative client whose diabetes has been well controlled on acarbose (Precose). The client is not allowed to take anything orally following complications of abdominal surgery and is receiving high-glucose total parenteral nutrition via a central IV line. What medication can the nurse administer intravenously to control the client's blood glucose level?
Regular insulin Explanation: Only regular insulin can be administered IV. No other insulins or oral antidiabetic medications can be given IV.
A client is admitted to the Emergency Department in diabetic ketoacidosis (DKA) with a blood glucose level of 33 mmol/L. The provider orders an initial dose of 25 U insulin IV. Which type of insulin will be administered?
Regular insulin Explanation: Regular insulin is a short-acting insulin that manages the hyperglycemia and hyperkalemia of DKA (diabetic ketoacidosis), which is a life-threatening complication that occurs with severe insulin deficiency. Humulin N, Humulin L, and NPH are intermediate-acting insulins.
A nurse is preparing an in-service presentation for a group of staff members on diabetes. Which would the nurse include as the primary delivery system for insulin?
Subcutaneous injection Explanation: Although other delivery systems are available for insulin administration such as the jet injector, insulin pen, and external pump, subcutaneous injection remains the primary delivery system.
After teaching a group of students about the various methods for the delivery of insulin, the instructor determines that the teaching was successful when the students identify which method as most commonly used for administration?
Subcutaneous injection Explanation: Subcutaneous injection currently is the most common method for administering insulin.
The nurse is conducting a class for newly diagnosed adult diabetic patients. What would the nurse educate the patients about?
The disease Explanation: While it would be important to teach the patients about nutrition, the preservation of intact skin and self-care, adults need extensive education about the disease as well as the drug therapy. Warning signs and symptoms should be stressed repeatedly as the adult learns to juggle insulin needs with exercise, stressors, other drug effects, and diet.
Regular insulin may be administered intravenously or intramuscularly in an emergency situation.
True Explanation: Regular insulin is given IM or IV in emergency situations.
In what condition is human insulin not recommended for diabetic clients?
Type 2 diabetes controlled by diet Explanation: Insulin is recommended for treatment of type 2 diabetes mellitus in clients whose diabetes cannot be controlled by diet or other agents. If the diabetes can be controlled by diet, the pancreas is still functioning and releasing insulin. Type 2 diabetes is characterized by hyperglycemia and insulin resistance. The hyperglycemia results from increased production of glucose by the liver and decreased uptake of glucose in liver, muscle, and fat cells. Insulin resistance means that higher-than-usual concentrations of insulin are required. Thus, insulin is present, but unable to work effectively at the cellular level. Diet control requires a reduction of ingested calories, which lowers the serum glucose levels. Human insulin can be used in gestational diabetes, type 2 diabetics controlled on oral antidiabetic agents with systemic infection, or type 1 diabetics of many years.
A 2-month-old male child is diagnosed with diabetes. His parents are having difficulty measuring 2 units of insulin in the U-100 syringe. What would the nurse expect the health care provider to order?
U-10 (10 units/mL) insulin Explanation: Administration of insulin for infants and toddlers who weigh less than 10 kg or require less than 5 units of insulin per day can be difficult because small doses are hard to measure in a U-100 syringe. Use of diluted insulin allows more accurate administration. The most common dilution strength is U-10 (10 units/mL), and a diluent is available from insulin manufacturers for this purpose. Vials of diluted insulin should be clearly labeled and should be discarded after 1 month.
The nurse is caring for a client who is taking glyburide as treatment for type 2 diabetes mellitus. The health care provider has added a corticosteroid to this client's medication regimen for treatment of a severe allergic reaction. The nurse knows that this drug combination may cause what adverse effect on this client?
hyperglycemia Explanation: Corticosteroids increase insulin needs, so the client may develop hyperglycemia.
After reviewing information about different insulin preparations, a nursing student demonstrates understanding of the information when the student identifies which medication as an example of a long-acting insulin?
insulin glargine Explanation: Insulin glargine is an example of a long-acting insulin. Insulin lispro and insulin aspart are rapid-acting insulin. Isophane insulin suspension is an intermediate-acting insulin.
A nurse is preparing to administer a rapid-acting insulin. Which medication would the nurse most likely administer?
insulin lispro Explanation: Insulin lispro is an example of a rapid-acting insulin. Insulin glargine and insulin detemir are long-acting insulin. Isophane insulin suspension is an intermediate-acting insulin.
When considering the management of diabetic ketoacidosis (DKA), what type of insulin can be administered intravenously?
regular Explanation: Regular insulin (insulin injection) has a rapid onset of action and can be given intravenously. Therefore, it is the insulin of choice during acute situations, such as DKA, severe infection or other illness, and surgical procedures. All the other options are administered subcutaneously.
A client with diabetes is undergoing testing for glycosylated hemoglobin. The nurse instructs the client that this test measures average blood glucose over what time period?
the past 3 or 4 months Explanation: Glycosylated hemoglobin measures glucose control over the past 3 to 4 months. When blood glucose levels are high, glucose molecules attach to hemoglobin in the red blood cell. The longer the hyperglycemia lasts, the more glucose binds to the red blood cell and the higher the glycosylated hemoglobin. This binding lasts for the life of the red blood cell (about 4 months) so the other time frames would not be accurate.
A 35-year-old client has begun the administration of glyburide for treatment of diabetes mellitus type 2. The nurse caring for this client provides education regarding this medication. Which statement would NOT be an appropriate instruction for this client?
The medication should have a fixed dose which cannot be manipulated. Explanation: Manipulating the dosing of glyburide can often reduce the unpleasant reactions. The primary adverse effect associated with glyburide (and the other sulfonylureas) is hypoglycemia. Concomitant alcohol use increases the rate of glyburide metabolism and may cause a disulfiram-like reaction. Administer glyburide before breakfast or the first main meal of the day in order to stimulate insulin production. It is important to caution clients to avoid taking OTC medications and herbal or dietary supplements without first consulting the prescriber.
