Chapter 51- Management of Patients with Diabetes

What is the only insulin that can be given intravenously?

Regular Explanation: Insulins other than regular are in suspensions that could be harmful if administered IV.

Lispro (Humalog) is an example of which type of insulin?

Rapid-acting Explanation: 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).

A client is admitted to the unit with diabetic ketoacidosis (DKA). Which insulin would the nurse expect to administer intravenously?

Regular Explanation: Regular insulin is administered intravenously to treat DKA. It is added to an IV solution and infused continuously. Glargine, NPH, and Lente are only administered subcutaneously.

A nurse is preparing a client with type 1 diabetes for discharge. The client can care for himself; however, he’s had a problem with unstable blood glucose levels in the past. Based on the client’s history, he should be referred to which health care worker?

Dietitian Explanation: The client should be referred to a dietitian, who will help him gain better control of his blood glucose levels. The client can care for himself, so a home health agency isn’t necessary. The client shows no signs of needing a psychiatric referral, and referring the client to a psychiatrist isn’t in the nurse’s scope of practice. Social workers help clients with financial concerns; the scenario doesn’t indicate that the client has a financial concern warranting a social worker at this time.

A nurse is providing dietary instructions to a client with hypoglycemia. To control hypoglycemic episodes, the nurse should recommend:

consuming a low-carbohydrate, high-protein diet and avoiding fasting. Explanation: To control hypoglycemic episodes, the nurse should instruct the client to consume a low-carbohydrate, high-protein diet, avoid fasting, and avoid simple sugars. Increasing saturated fat intake and increasing vitamin supplementation wouldn’t help control hypoglycemia.

Which of the following factors should the nurse take into consideration when planning meals and selecting the type and dosage of insulin or oral hypoglycemic agent for an elderly client with diabetes mellitus?

Client’s eating and sleeping habits. Explanation: The eating and sleeping habits of older adults differ from those of young or middle-aged persons. The nurse should take into consideration when planning meals and selecting the proper type and dosage of insulin or oral hypoglycemic agent.

Which of the following would the nurse most likely assess in a client with diabetes who is experiencing autonomic neuropathy?

Erectile dysfunction Explanation: Autonomic neuropathy affects organ functioning. According the American Diabetes Association, up to 50% of men with diabetes develop erectile dysfunction when nerves that promote erection become impaired. Skeletal deformities and soft tissue ulcers may occur with motor neuropathy. Paresthesias are associated with sensory neuropathy.

A client’s blood glucose level is 45 mg/dl. The nurse should be alert for which signs and symptoms?

Coma, anxiety, confusion, headache, and cool, moist skin Explanation: Signs and symptoms of hypoglycemia (indicated by a blood glucose level of 45 mf/dl) include anxiety, restlessness, headache, irritability, confusion, diaphoresis, cool skin, tremors, coma, and seizures. Kussmaul’s respirations, dry skin, hypotension, and bradycardia are signs of diabetic ketoacidosis. Excessive thirst, hunger, hypotension, and hypernatremia are symptoms of diabetes insipidus. Polyuria, polydipsia, polyphagia, and weight loss are classic signs and symptoms of diabetes mellitus.

Which of the following clinical characteristics is associated with Type 1 diabetes (previously referred to as insulin-dependent diabetes mellitus [IDDM])?

Presence of islet cell antibodies Explanation: Individuals with type 1 diabetes often have islet cell antibodies. Individuals with type 1 diabetes are usually thin or demonstrate recent weight loss at the time of diagnosis. Individuals with type 1 diabetes are ketosis-prone when insulin is absent. Individuals with type 1 diabetes need insulin to preserve life.

A client with type 2 diabetes asks the nurse why he can’t have a pancreatic transplant. Which of the following would the nurse include as a possible reason?

Underlying problem of insulin resistance Explanation: Clients with type 2 diabetes are not offered the option of a pancreas transplant because their problem is insulin resistance, which does not improve with a transplant. Urologic complications or the need for exocrine enzymatic drainage are not reasons for not offering pancreas transplant to clients with type 2 diabetes. Any transplant requires lifelong immunosuppressive drug therapy and is not the factor.

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. Explanation: 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 client with long-standing type 1 diabetes is admitted to the hospital with unstable angina pectoris. After the client’s condition stabilizes, the nurse evaluates the diabetes management regimen. The nurse learns that the client sees the physician every 4 weeks, injects insulin after breakfast and dinner, and measures blood glucose before breakfast and at bedtime. Consequently, the nurse should formulate a nursing diagnosis of:

Deficient knowledge (treatment regimen). Explanation: The client should inject insulin before, not after, breakfast and dinner — 30 minutes before breakfast for the a.m. dose and 30 minutes before dinner for the p.m. dose. Therefore, the client has a knowledge deficit regarding when to administer insulin. By taking insulin, measuring blood glucose levels, and seeing the physician regularly, the client has demonstrated the ability and willingness to modify his lifestyle as needed to manage the disease. This behavior eliminates the nursing diagnoses of Impaired adjustment and Defensive coping. Because the nurse, not the client, questioned the client’s health practices related to diabetes management, the nursing diagnosis of Health-seeking behaviors isn’t warranted.

Which combination of adverse effects should a nurse monitor for when administering I.V. insulin to a client with diabetic ketoacidosis?

Hypokalemia and hypoglycemia Explanation: Blood glucose needs to be monitored in clients receiving I.V. 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. Calcium and sodium levels aren’t affected by I.V. insulin administration.

Insulin is secreted by which of the following types of cells?

Beta cells Explanation: Insulin is secreted by the beta cells, in the islets of Langerhans of the pancreas. In diabetes, cells may stop responding to insulin, or the pancreas may decrease insulin secretion or stop insulin production completely. Melanocytes are what give the skin its pigment. Neural cells transmit impulses in the brain and spinal cord. Basal cells are a type of skin cell.

Which of the following clinical manifestations of type 2 diabetes occurs if glucose levels are very high?

Blurred vision Explanation: Blurred vision occurs when the blood glucose levels are very high. The other clinical manifestations are not consistent with type 2 diabetes.

Which of the following is the most rapid acting insulin?

Humalog Explanation: The onset of action of rapid-acting Humalog 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 is 3 to 4 hours. The onset of action of long-acting Ultralente is 6 to 8 hours.

A client is admitted with hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which laboratory finding should the nurse expect in this client?

Blood glucose level 1,100 mg/dl Explanation: HHNS occurs most frequently in older clients. It can occur in clients with either type 1 or type 2 diabetes mellitus but occurs most commonly in those with type 2. The blood glucose level rises to above 600 mg/dl in response to illness or infection. As the blood glucose level rises, the body attempts to rid itself of the excess glucose by producing urine. Initially, the client produces large quantities of urine. If fluid intake isn’t increased at this time, the client becomes dehydrated, causing BUN levels to rise. Arterial pH and plasma bicarbonate levels typically remain within normal limits.

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. Explanation: 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.

A patient with diabetes mellitus is receiving an oral antidiabetic agent. The nurse observes for which of the following symptoms when caring for this patient?

Signs of hypoglycemia Explanation: The nurse should observe the patient receiving an oral antidiabetic agent for the signs of hypoglycemia. The time when the reaction might occur is not predictable and could be from 30 to 60 minutes to several hours after the drug is ingested. Polyuria, polydipsia, and blurred vision are the symptoms of diabetes mellitus.

The nurse is preparing a presentation for a group of adults at a local community center about diabetes. Which of the following would the nurse include as associated with type 2 diabetes?

Insulin production insufficient Explanation: Type 2 diabetes is characterized by insulin resistance or insufficient insulin production. It is more common in aging adults, and now accounts for 20% of all newly diagnosed cases. Type 1 diabetes is more likely in childhood and adolescence although it can occur at any age. It accounts for approximately 5% to 10% of all diagnosed cases of diabetes. Pre-diabetes can lead to type 2 diabetes.

A client with type 2 diabetes asks the nurse why he can’t have a pancreatic transplant. Which of the following would the nurse include as a possible reason?

Underlying problem of insulin resistance Explanation: Clients with type 2 diabetes are not offered the option of a pancreas transplant because their problem is insulin resistance, which does not improve with a transplant. Urologic complications or the need for exocrine enzymatic drainage are not reasons for not offering pancreas transplant to clients with type 2 diabetes. Any transplant requires lifelong immunosuppressive drug therapy and is not the factor.

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 Explanation: 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. Epinephrine isn’t a treatment for hypoglycemia. Although 50% dextrose is used to treat hypoglycemia, it must be administered I.V. by a skilled health care professional. Hydrocortisone takes a relatively long time to raise the blood glucose level and therefore isn’t effective in reversing hypoglycemia.

A client with diabetes is receiving an oral antidiabetic agent that acts to help the tissues use available insulin more efficiently. Which of the following agents would the nurse expect to administer?

Metformin Explanation: 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.

A client with diabetes mellitus is prescribed to switch from animal to synthesized human insulin. Which of the following factors should the nurse monitor when caring for the client?

Low blood glucose levels Explanation: Clients who switch from animal to synthesized human insulin should be monitored for low blood glucose levels initially because the human form of insulin is used more effectively.

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 Explanation: 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.

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 Explanation: 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.

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." Explanation: 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. Thus, this type of transplant doesn’t cure diabetes. It requires the use of two human pancreases to obtain sufficient numbers of islet cells for transplantation. A whole organ transplant requires a means for exocrine enzyme drainage and venous absorption of insulin.

Which of the following clinical characteristics is associated with type 2 diabetes (previously referred to as non-insulin dependent diabetes mellitus [NIDDM])?

Can control blood glucose through diet and exercise Explanation: Oral hypoglycemic agents may improve blood glucose levels if dietary modification and exercise are unsuccessful. Individuals with type 2 diabetes are usually obese at diagnosis. Individuals with type 2 diabetes rarely demonstrate ketosis, except with stress or infection. Individuals with type 2 diabetes do not demonstrate islet cell antibodies.

Which of the following may be a potential cause of hypoglycemia in the patient diagnosed with diabetes mellitus?

The patient has not consumed food and continues to take insulin or oral antidiabetic medications. Explanation: Hypoglycemia occurs when a patient with diabetes is not eating at all and continues to take insulin or oral antidiabetic medications. Hypoglycemia does not occur when the patient has not been compliant with the prescribed treatment regimen. If the patient has eaten and has not taken or received insulin, DKA is more likely to develop.

A nurse expects to note an elevated serum glucose level in a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which other laboratory finding should the nurse anticipate?

Below-normal serum potassium level Explanation: A client with HHNS has an overall body deficit of potassium resulting from diuresis, which occurs secondary to the hyperosmolar, hyperglycemic state caused by the relative insulin deficiency. An elevated serum acetone level and serum ketone bodies are characteristic of diabetic ketoacidosis. Metabolic acidosis, not serum alkalosis, may occur in HHNS.

Which of the following statements is correct regarding glargine (Lantus) insulin?

It cannot be mixed with any other type of insulin. Explanation: Because this insulin is in a suspension with a pH of 4, it cannot be mixed with other insulins because this would cause precipitation. There is not a peak in action. It is approved to give once daily

A nurse explains to a client that she will administer his first insulin dose in his abdomen. How does absorption at the abdominal site compare with absorption at other sites?

Insulin is absorbed more rapidly at abdominal injection sites than at other sites. Explanation: Subcutaneous insulin is absorbed most rapidly at abdominal injection sites, more slowly at sites on the arms, and slowest at sites on the anterior thigh. Absorption after injection in the buttocks is less predictable.

Which intervention is essential when performing dressing changes on a client with a diabetic foot ulcer?

Using sterile technique during the dressing change Explanation: The nurse should perform the dressing changes using sterile technique to prevent infection. Applying heat should be avoided in a client with diabetes mellitus because of the risk of injury. Cleaning the wound with povidone-iodine solution and debriding the wound with each dressing change prevents the development of granulation tissue, which is essential in the wound healing process.

A client with type 1 diabetes has a highly elevated glycosylated hemoglobin (Hb) test result. In discussing the result with the client, the nurse is most accurate in stating:

"It tells us about your sugar control for the last 3 months." Explanation: The nurse is providing accurate information to the client when she states that the glycosylated Hb test provides an objective measure of glycemic control over a 3-month period. The test helps identify trends or practices that impair glycemic control, and it doesn’t require a fasting period before blood is drawn. The nurse can’t conclude that the result occurs from poor dietary management or inadequate insulin coverage.

When administering insulin to a client with type 1 diabetes, which of the following would be most important for the nurse to keep in mind?

Accuracy of the dosage Explanation: The measurement of insulin is most important and must be accurate because clients may be sensitive to minute dose changes. The duration, area, and technique for injecting should also to be noted.

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. Explanation: 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.

A hospitalized client is found to be comatose and hypoglycemic with a blood sugar of 50 mg/dL. Which of the following would the nurse do first?

Administer 50% glucose intravenously. Explanation: The unconscious, hypoglycemic client needs immediate treatment with IV glucose. If the client does not respond quickly and the blood glucose level continues to be low, glucagon, a hormone that stimulates the liver to release glycogen, or 20 to 50 mL of 50% glucose is prescribed for IV administration. A dose of 1,000 mL D5W over a 12-hour period indicates a lower strength of glucose and a slow administration rate. Checking the client’s urine for the presence of sugar and acetone is incorrect because a blood sample is easier to collect and the blood test is more specific and reliable. An unconscious client cannot be given a drink. In such a case glucose gel may be applied in the buccal cavity of the mouth.

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." Explanation: 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 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. Explanation: 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.

After teaching a group of students about diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic nonketotic syndrome (HHNKS), the instructor determines that additional teaching is needed when the students identify which of the following as characteristic of HHNKS?

Elevated serum potassium levels Explanation: With HHNKS, blood glucose are significantly increased, well over 500 mg/dL, blood pH remains within the normal range of 7.35 to 7.45, and serum potassium and sodium levels are low.

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. Explanation: The nurse should instruct the client to administer 1 unit of insulin for every 15 g of carbohydrates

A male client, aged 42, is diagnosed with diabetes mellitus. He visits the gym regularly and is a vegetarian. Which of the following factors is important when assessing the client?

The client’s consumption of carbohydrates Explanation: While assessing a client, it is important to note the client’s consumption of carbohydrates because he has 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 as important to information related to the client’s to be noted in a client with high blood sugar.

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 transport of glucose across the cell wall. Explanation: 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.

What is the duration of regular insulin?

4 to 6 hours Explanation: 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.

Once digested, what percentage of carbohydrates is converted to glucose?

100 Explanation: Once digested, 100% of carbohydrates are converted to glucose. However, approximately 40% of protein foods are also converted to glucose, but this has minimal effect on blood glucose levels.

A client with diabetes is receiving an oral antidiabetic agent that acts to help the tissues use available insulin more efficiently. Which of the following agents would the nurse expect to administer?

Metformin Explanation: 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.

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. Explanation: 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.

The nurse is providing information about foot care to a client with diabetes. Which of the following would the nurse include?

"Be sure to apply a moisturizer to feet daily." Explanation: The nurse should advise the client to apply a moisturizer to the feet daily. The client should use warm water not hot water to bathe his feet. Razors to remove corns or calluses must be avoided to prevent injury and infection. The client should wear well-fitting comfortable shoes, avoiding shoes made of rubber, plastic or vinyl which would cause the feet to perspire.

A client is admitted with hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which laboratory finding should the nurse expect in this client?

Blood glucose level 1,100 mg/dl Explanation: HHNS occurs most frequently in older clients. It can occur in clients with either type 1 or type 2 diabetes mellitus but occurs most commonly in those with type 2. The blood glucose level rises to above 600 mg/dl in response to illness or infection. As the blood glucose level rises, the body attempts to rid itself of the excess glucose by producing urine. Initially, the client produces large quantities of urine. If fluid intake isn’t increased at this time, the client becomes dehydrated, causing BUN levels to rise. Arterial pH and plasma bicarbonate levels typically remain within normal limits.

The nurse is reviewing the initial laboratory test results of a client diagnosed with DKA. Which of the following would the nurse expect to find?

Blood pH of 6.9 Explanation: With DKA, blood glucose levels are elevated to 300 to 1000 mg/dL or more. Urine contains glucose and ketones. The blood pH ranges from 6.8 to 7.3. The serum bicarbonate level is decreased to levels from 0 to 15 mEq/L. The compensatory breathing pattern can lower the partial pressure of carbon dioxide in arterial blood (PaCO2) to levels of 10 to 30 mm Hg.

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. Explanation: 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.

Which of the following medications is considered a glitazone?

Actos Explanation: Pioglitazone (Actos) and rosiglitazone (Avandia) are classified as a glitazone or thiazolidinedione. Metformin (Glucophage, Glucophase) and metformin with glyburide (Glucovance) are classified as biguanides.

A client with type 1 diabetes is scheduled to receive 30 units of 70/30 insulin. There is no 70/30 insulin available. As a substitution, the nurse may give the client:

9 units regular insulin and 21 units neutral protamine Hagedorn (NPH). Explanation: A 70/30 insulin preparation is 70% NPH and 30% regular insulin. Therefore, a correct substitution requires mixing 21 units of NPH and 9 units of regular insulin. The other choices are incorrect dosages for the ordered insulin.

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 Explanation: 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. Cheyne-Stokes respirations are characterized by a period of apnea lasting 10 to 60 seconds, followed by gradually increasing depth and frequency of respirations. Cheyne-Stokes respirations typically occur with cerebral depression or heart failure.

Which of the following categories of oral antidiabetic agents exert their primary action by directly stimulating the pancreas to secrete insulin?

Sulfonylureas Explanation: A functioning pancreas is necessary for sulfonylureas to be effective. Thiazolidinediones enhance insulin action at the receptor site without increasing insulin secretion from the beta cells of the pancreas. Biguanides facilitate insulin’s action on peripheral receptor sites. Alpha glucosidase inhibitors delay the absorption of glucose in the intestinal system, resulting in a lower postprandial blood glucose level.

An obese Hispanic client, age 65, is diagnosed with type 2 diabetes. Which statement about diabetes mellitus is true?

Diabetes mellitus is more common in Hispanics and Blacks than in Whites. Explanation: Diabetes mellitus is more common in Hispanics and Blacks than in Whites. Only about one-third of clients with diabetes mellitus are older than age 60 and 85% to 90% have type 2. At least 80% of clients diagnosed with type 2 diabetes mellitus are obese.

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 Explanation: 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.

A 53-year-old client is brought to the ED, via squad, where you practice nursing. He is demonstrating fast, deep, labored breathing and has a fruity odor to his breath. He has a history of type 1 diabetes. What could be the cause of his current serious condition?

Ketoacidosis Explanation: 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.

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 (Tolinase). Which laboratory test is the most important for confirming this disorder?

Serum osmolarity Explanation: 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.

After taking glipizide (Glucotrol) for 9 months, a client experiences secondary failure. What should the nurse expect the physician to do?

Switch the client to a different oral antidiabetic agent. Explanation: The nurse should anticipate that the physician will order a different oral antidiabetic agent. Many clients (25% to 60%) who take glipizide respond to a different oral antidiabetic agent. Therefore, it wouldn’t be appropriate to initiate insulin therapy at this time. However, if a new oral antidiabetic agent is unsuccessful in keeping glucose levels at an acceptable level, insulin may be used in addition to the antidiabetic agent. Restricting carbohydrate intake isn’t necessary.

A 32-year-old client has an appointment at the weight loss clinic where you practice nursing. She has gained 55 lbs. in the last three years and is concerned about developing Type 2 diabetes mellitus, especially since her parents both have developed the disorder. What are the conditions which contribute to developing metabolic syndrome? Choose all correct options.

• Abdominal obesity • Elevated blood glucose levels Explanation: Some experts believe that diabetes in adults is one consequence of metabolic syndrome, which includes elevated blood glucose levels, hypertension, hypercholesterolemia, and abdominal obesity.

For a client with hyperglycemia, which assessment finding best supports a nursing diagnosis of Deficient fluid volume?

Increased urine osmolarity Explanation: In hyperglycemia, urine osmolarity (the measurement of dissolved particles in the urine) increases as glucose particles move into the urine. The client experiences glucosuria and polyuria, losing body fluids and experiencing deficient fluid volume. Cool, clammy skin; jugular vein distention; and a decreased serum sodium level are signs of fluid volume excess, the opposite imbalance.

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. Explanation: The beta cells of the pancreas secrete insulin. The adenohypophysis, or anterior pituitary gland, secretes many hormones, such as growth hormone, prolactin, thyroid-stimulating hormone, corticotropin, follicle-stimulating hormone, and luteinizing hormone, but not insulin. The alpha cells of the pancreas secrete glucagon, which raises the blood glucose level. The parafollicular cells of the thyroid secrete the hormone calcitonin, which plays a role in calcium metabolism.

A client is diagnosed with diabetes mellitus. Which assessment finding best supports a nursing diagnosis of Ineffective coping related to diabetes mellitus?

Crying whenever diabetes is mentioned Explanation: A client who cries whenever diabetes is mentioned is demonstrating ineffective coping. A recent weight gain and failure to monitor blood glucose levels would support a nursing diagnosis of Noncompliance: Failure to adhere to therapeutic regimen. Skipping insulin doses during illness would support a nursing diagnosis of Deficient knowledge related to treatment of diabetes mellitus.

A client with type 1 diabetes must undergo bowel resection in the morning. How should the nurse proceed while caring for him on the morning of surgery?

Administer half of the client’s typical morning insulin dose as ordered. Explanation: If the nurse administers the client’s normal daily dose of insulin while he’s on nothing-by-mouth status before surgery, he’ll experience hypoglycemia. Therefore, the nurse should administer half the daily insulin dose as ordered. Oral antidiabetic agents aren’t effective for type 1 diabetes. I.V. insulin infusions aren’t necessary to manage blood glucose levels in clients undergoing routine surgery.

Which of the following are byproducts of fat breakdown, which accumulate in the blood and urine?

Ketones Explanation: Ketones are byproducts of fat breakdown, and they accumulate in the blood and urine. Creatinine, hemoglobin, and cholesterol are not byproducts of fat breakdown.

Which of the following factors should the nurse take into consideration when planning meals and selecting the type and dosage of insulin or oral hypoglycemic agent for an elderly patient with diabetes mellitus?

Patient’s eating and sleeping habits Explanation: The eating and sleeping habits of older adults differ from those of young or middle-aged persons. The nurse should take this into consideration when planning meals and selecting the proper type and dosage of insulin or oral hypoglycemic agent. The nurse should evaluate the patient’s ability to self-administer insulin before developing a teaching program. Cognitive problems and patient history may not be taken into consideration when planning meals and selecting the proper type and dosage of insulin or oral hypoglycemic agent.

A client is receiving insulin lispro at 7:30 AM. The nurse ensures that the client has breakfast by which time?

7:35 AM Explanation: Insulin lispro has an onset of 10 to 15 minutes. Therefore, the nurse would need to ensure that the client has his breakfast by 7:35 AM. Otherwise, the client may experience hypoglycemia.

Which of the following is a characteristic of diabetic ketoacidosis (DKA)? Select all that apply.

• Elevated blood urea nitrogen (BUN) and creatinine • Rapid onset • More common in type 1 diabetes Explanation: DKA is characterized by an elevated BUN and creatinine, rapid onset, and it is more common in type 1 diabetes. Hyperglycemic hyperosmolar nonketotic syndrome (HHNS) is characterized by the absence of urine and serum ketones and a normal arterial pH level.

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 I.V. 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 I.V. solution to dextrose 5% in water. Explanation: The nurse should question the physician’s order to change the second I.V. solution to dextrose 5% in water. The client should receive normal saline solution through the second I.V. 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.

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. Explanation: Controlling blood glucose levels and any hypertension can prevent or delay the development of diabetic nephropathy. Drinking plenty of fluids does not prevent diabetic nephropathy. Taking antidiabetic drugs regularly may help to control blood glucose levels, but it is the control of these levels that is most important. A high-fiber diet is unrelated to the development of diabetic nephropathy

A group of students are reviewing the various types of drugs that are used to treat diabetes mellitus. The students demonstrate understanding of the material when they identify which of the following as an example of an alpha-glucosidase inhibitor?

Miglitol Explanation: Alpha-glucosidase inhibitors include drugs such as miglitol and acarbose. Metformin is a biguanide. Glyburide is a sulfonylurea. Rosiglitazone is a thiazolidinedione.

As a nurse educator, you have been invited to your local senior center to discuss health-maintaining strategies for older adults. During your education session on nutrition, you approach the subject of diabetes mellitus, its symptoms and consequences. What is the prevalence of Type I diabetes?

5% to 10% of all diagnosed cases Explanation: Type 1 diabetes accounts for approximately 5% to 10% of all diagnosed cases of diabetes (National Institute of Diabetes and Digestive and Kidney Diseases [NIDDK], 2008).

Which of the following factors is the focus of nutrition intervention for clients with type 2 diabetes?

Weight loss Explanation: Weight loss is the focus of nutrition intervention for clients with Type 2 diabetes. A low-calorie diet may improve clinical symptoms; even a mild to moderate weight loss such as 10 to 20 lb may lower blood glucose levels and improve insulin action.

The nurse is preparing a presentation for a group of adults at a local community center about diabetes. Which of the following would the nurse include as associated with type 2 diabetes?

Insulin production insufficient Explanation: Type 2 diabetes is characterized by insulin resistance or insufficient insulin production. It is more common in aging adults, and now accounts for 20% of all newly diagnosed cases. Type 1 diabetes is more likely in childhood and adolescence although it can occur at any age. It accounts for approximately 5% to 10% of all diagnosed cases of diabetes. Pre-diabetes can lead to type 2 diabetes.

After teaching a group of students about diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic nonketotic syndrome (HHNKS), the instructor determines that additional teaching is needed when the students identify which of the following as characteristic of HHNKS?

Elevated serum potassium levels Explanation: With HHNKS, blood glucose are significantly increased, well over 500 mg/dL, blood pH remains within the normal range of 7.35 to 7.45, and serum potassium and sodium levels are low.

A nurse is developing a teaching plan for a client with diabetes mellitus. A client with diabetes mellitus should:

wash and inspect the feet daily. Explanation: A client with diabetes mellitus should wash and inspect his feet daily and should wear nonconstrictive shoes. Corns should be treated by a podiatrist — not with commercial preparations. Nails should be filed straight across. Clients with diabetes mellitus should never walk barefoot.

Which of the following would be included in the teaching plan for a patient diagnosed with diabetes mellitus?

Elevated blood glucose levels contribute to complications of diabetes, such as diminished vision. Explanation: When blood glucose levels are well controlled, the potential for complications of diabetes is reduced. Several types of foods contain sugar, including cereals, sauces, salad dressing, fruit, and fruit juices. It is not feasible, nor is it advisable, to remove all sources of sugar from the diet. If the diabetes had been well controlled without insulin prior to the period of acute stress causing the need for insulin, the patient may be able to resume previous methods for control of diabetes when the stress is resolved.

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." Explanation: 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.