Chapter 49: Nursing Management: Diabetes Mellitus

Question 1

1. Which statement by a nurse to a patient newly diagnosed with type 2 diabetes is correct?

a.

Insulin is not used to control blood glucose in patients with type 2 diabetes.

b.

Complications of type 2 diabetes are less serious than those of type 1 diabetes.

c.

Changes in diet and exercise may control blood glucose levels in type 2 diabetes.

d.

Type 2 diabetes is usually diagnosed when the patient is admitted with a hyperglycemic coma.

Answer 1

ANS: C

For some patients with type 2 diabetes, changes in lifestyle are sufficient to achieve blood glucose control. Insulin is frequently used for type 2 diabetes, complications are equally severe as for type 1 diabetes, and type 2 diabetes is usually diagnosed with routine laboratory testing or after a patient develops complications such as frequent yeast infections.

Question 2

2. A 48-year-old male patient screened for diabetes at a clinic has a fasting plasma glucose level of 120 mg/dL (6.7 mmol/L). The nurse will plan to teach the patient about

a.

self-monitoring of blood glucose.

b.

using low doses of regular insulin.

c.

lifestyle changes to lower blood glucose.

d.

effects of oral hypoglycemic medications.

Answer 2

ANS: C

The patients impaired fasting glucose indicates prediabetes, and the patient should be counseled about lifestyle changes to prevent the development of type 2 diabetes. The patient with prediabetes does not require insulin or oral hypoglycemics for glucose control and does not need to self-monitor blood glucose.

Question 3

3. A 28-year-old male patient with type 1 diabetes reports how he manages his exercise and glucose control. Which behavior indicates that the nurse should implement additional teaching?

a.

The patient always carries hard candies when engaging in exercise.

b.

The patient goes for a vigorous walk when his glucose is 200 mg/dL.

c.

The patient has a peanut butter sandwich before going for a bicycle ride.

d.

The patient increases daily exercise when ketones are present in the urine.

Answer 3

ANS: D

When the patient is ketotic, exercise may result in an increase in blood glucose level. Type 1 diabetic patients should be taught to avoid exercise when ketosis is present. The other statements are correct.

Question 4

4. The nurse is assessing a 22-year-old patient experiencing the onset of symptoms of type 1 diabetes. Which question is most appropriate for the nurse to ask?

a.

Are you anorexic?

b.

Is your urine dark colored?

c.

Have you lost weight lately?

d.

Do you crave sugary drinks?

Answer 4

ANS: C

Weight loss occurs because the body is no longer able to absorb glucose and starts to break down protein and fat for energy. The patient is thirsty but does not necessarily crave sugar-containing fluids. Increased appetite is a classic symptom of type 1 diabetes. With the classic symptom of polyuria, urine will be very dilute.

Question 5

5. A patient with type 2 diabetes is scheduled for a follow-up visit in the clinic several months from now. Which test will the nurse schedule to evaluate the effectiveness of treatment for the patient?

a.

Urine dipstick for glucose

b.

Oral glucose tolerance test

c.

Fasting blood glucose level

d.

Glycosylated hemoglobin level

Answer 5

ANS: D

The glycosylated hemoglobin (A1C or HbA1C) test shows the overall control of glucose over 90 to 120 days. A fasting blood level indicates only the glucose level at one time. Urine glucose testing is not an accurate reflection of blood glucose level and does not reflect the glucose over a prolonged time. Oral glucose tolerance testing is done to diagnose diabetes, but is not used for monitoring glucose control once diabetes has been diagnosed.

Question 6

6. A 55-year-old female patient with type 2 diabetes has a nursing diagnosis of imbalanced nutrition: more than body requirements. Which goal is most important for this patient?

a.

The patient will reach a glycosylated hemoglobin level of less than 7%.

b.

The patient will follow a diet and exercise plan that results in weight loss.

c.

The patient will choose a diet that distributes calories throughout the day.

d.

The patient will state the reasons for eliminating simple sugars in the diet.

Answer 6

ANS: A

The complications of diabetes are related to elevated blood glucose, and the most important patient outcome is the reduction of glucose to near-normal levels. The other outcomes also are appropriate but are not as high in priority.

Question 7

7. A 38-year-old patient who has type 1 diabetes plans to swim laps daily at 1:00 PM. The clinic nurse will plan to teach the patient to

a.

check glucose level before, during, and after swimming.

b.

delay eating the noon meal until after the swimming class.

c.

increase the morning dose of neutral protamine Hagedorn (NPH) insulin.

d.

time the morning insulin injection so that the peak occurs while swimming.

Answer 7

ANS: A

The change in exercise will affect blood glucose, and the patient will need to monitor glucose carefully to determine the need for changes in diet and insulin administration. Because exercise tends to decrease blood glucose, patients are advised to eat before exercising. Increasing the morning NPH or timing the insulin to peak during exercise may lead to hypoglycemia, especially with the increased exercise.

Question 8

8. The nurse determines a need for additional instruction when the patient with newly diagnosed type 1 diabetes says which of the following?

a.

I can have an occasional alcoholic drink if I include it in my meal plan.

b.

I will need a bedtime snack because I take an evening dose of NPH insulin.

c.

I can choose any foods, as long as I use enough insulin to cover the calories.

d.

I will eat something at meal times to prevent hypoglycemia, even if I am not hungry.

Answer 8

ANS: C

Most patients with type 1 diabetes need to plan diet choices very carefully. Patients who are using intensified insulin therapy have considerable flexibility in diet choices but still should restrict dietary intake of items such as fat, protein, and alcohol. The other patient statements are correct and indicate good understanding of the diet instruction.

Question 9

9. In order to assist an older diabetic patient to engage in moderate daily exercise, which action is most important for the nurse to take?

a.

Determine what type of activities the patient enjoys.

b.

Remind the patient that exercise will improve self-esteem.

c.

Teach the patient about the effects of exercise on glucose level.

d.

Give the patient a list of activities that are moderate in intensity.

Answer 9

ANS: A

Because consistency with exercise is important, assessment for the types of exercise that the patient finds enjoyable is the most important action by the nurse in ensuring adherence to an exercise program. The other actions will also be implemented but are not the most important in improving compliance.

Question 10

10. Which statement by the patient indicates a need for additional instruction in administering insulin?

a.

I need to rotate injection sites among my arms, legs, and abdomen each day.

b.

I can buy the 0.5 mL syringes because the line markings will be easier to see.

c.

I should draw up the regular insulin first after injecting air into the NPH bottle.

d.

I do not need to aspirate the plunger to check for blood before injecting insulin.

Answer 10

ANS: A

Rotating sites is no longer recommended because there is more consistent insulin absorption when the same site is used consistently. The other patient statements are accurate and indicate that no additional instruction is needed.

Question 11

11. Which patient action indicates good understanding of the nurses teaching about administration of aspart (NovoLog) insulin?

a.

The patient avoids injecting the insulin into the upper abdominal area.

b.

The patient cleans the skin with soap and water before insulin administration.

c.

The patient stores the insulin in the freezer after administering the prescribed dose.

d.

The patient pushes the plunger down while removing the syringe from the injection site.

Answer 11

ANS: B

Cleaning the skin with soap and water or with alcohol is acceptable. Insulin should not be frozen. The patient should leave the syringe in place for about 5 seconds after injection to be sure that all the insulin has been injected. The upper abdominal area is one of the preferred areas for insulin injection.

Question 12

12. A patient receives aspart (NovoLog) insulin at 8:00 AM. Which time will it be most important for the nurse to monitor for symptoms of hypoglycemia?

a.

10:00 AM

b.

12:00 AM

c.

2:00 PM

d.

4:00 PM

Answer 12

ANS: A

The rapid-acting insulins peak in 1 to 3 hours. The patient is not at a high risk for hypoglycemia at the other listed times, although hypoglycemia may occur.

Question 13

13. Which patient action indicates a good understanding of the nurses teaching about the use of an insulin pump?

a.

The patient programs the pump for an insulin bolus after eating.

b.

The patient changes the location of the insertion site every week.

c.

The patient takes the pump off at bedtime and starts it again each morning.

d.

The patient plans for a diet that is less flexible when using the insulin pump.

Answer 13

ANS: A

In addition to the basal rate of insulin infusion, the patient will adjust the pump to administer a bolus after each meal, with the dosage depending on the oral intake. The insertion site should be changed every 2 or 3 days. There is more flexibility in diet and exercise when an insulin pump is used. The pump will deliver a basal insulin rate 24 hours a day.

Question 14

14. A 32-year-old patient with diabetes is starting on intensive insulin therapy. Which type of insulin will the nurse discuss using for mealtime coverage?

a.

Lispro (Humalog)

b.

Glargine (Lantus)

c.

Detemir (Levemir)

d.

NPH (Humulin N)

Answer 14

ANS: A

Rapid- or short-acting insulin is used for mealtime coverage for patients receiving intensive insulin therapy. NPH, glargine, or detemir will be used as the basal insulin.

Question 15

15. Which information will the nurse include when teaching a 50-year-old patient who has type 2 diabetes about glyburide (Micronase, DiaBeta, Glynase)?

a.

Glyburide decreases glucagon secretion from the pancreas.

b.

Glyburide stimulates insulin production and release from the pancreas.

c.

Glyburide should be taken even if the morning blood glucose level is low.

d.

Glyburide should not be used for 48 hours after receiving IV contrast media.

Answer 15

ANS: B

The sulfonylureas stimulate the production and release of insulin from the pancreas. If the glucose level is low, the patient should contact the health care provider before taking the glyburide, because hypoglycemia can occur with this class of medication. Metformin should be held for 48 hours after administration of IV contrast media, but this is not necessary for glyburide. Glucagon secretion is not affected by glyburide.

Question 16

16. The nurse has been teaching a patient with type 2 diabetes about managing blood glucose levels and taking glipizide (Glucotrol). Which patient statement indicates a need for additional teaching?

a.

If I overeat at a meal, I will still take the usual dose of medication.

b.

Other medications besides the Glucotrol may affect my blood sugar.

c.

When I am ill, I may have to take insulin to control my blood sugar.

d.

My diabetes wont cause complications because I dont need insulin.

Answer 16

ANS: D

The patient should understand that type 2 diabetes places the patient at risk for many complications and that good glucose control is as important when taking oral agents as when using insulin. The other statements are accurate and indicate good understanding of the use of glipizide.

Question 17

17. When a patient who takes metformin (Glucophage) to manage type 2 diabetes develops an allergic rash from an unknown cause, the health care provider prescribes prednisone (Deltasone). The nurse will anticipate that the patient may

a.

need a diet higher in calories while receiving prednisone.

b.

develop acute hypoglycemia while taking the prednisone.

c.

require administration of insulin while taking prednisone.

d.

have rashes caused by metformin-prednisone interactions.

Answer 17

ANS: C

Glucose levels increase when patients are taking corticosteroids, and insulin may be required to control blood glucose. Hypoglycemia is not a side effect of prednisone. Rashes are not an adverse effect caused by taking metformin and prednisone simultaneously. The patient may have an increased appetite when taking prednisone, but will not need a diet that is higher in calories.

Question 18

18. A hospitalized diabetic patient received 38 U of NPH insulin at 7:00 AM. At 1:00 PM, the patient has been away from the nursing unit for 2 hours, missing the lunch delivery while awaiting a chest x-ray. To prevent hypoglycemia, the best action by the nurse is to

a.

save the lunch tray for the patients later return to the unit.

b.

ask that diagnostic testing area staff to start a 5% dextrose IV.

c.

send a glass of milk or orange juice to the patient in the diagnostic testing area.

d.

request that if testing is further delayed, the patient be returned to the unit to eat.

Answer 18

ANS: D

Consistency for mealtimes assists with regulation of blood glucose, so the best option is for the patient to have lunch at the usual time. Waiting to eat until after the procedure is likely to cause hypoglycemia. Administration of an IV solution is unnecessarily invasive for the patient. A glass of milk or juice will keep the patient from becoming hypoglycemic but will cause a rapid rise in blood glucose because of the rapid absorption of the simple carbohydrate in these items.

Question 19

19. The nurse identifies a need for additional teaching when the patient who is self-monitoring blood glucose

a.

washes the puncture site using warm water and soap.

b.

chooses a puncture site in the center of the finger pad.

c.

hangs the arm down for a minute before puncturing the site.

d.

says the result of 120 mg indicates good blood sugar control.

Answer 19

ANS: B

The patient is taught to choose a puncture site at the side of the finger pad because there are fewer nerve endings along the side of the finger pad. The other patient actions indicate that teaching has been effective.

Question 20

20. The nurse is preparing to teach a 43-year-old man who is newly diagnosed with type 2 diabetes about home management of the disease. Which action should the nurse take first?

a.

Ask the patients family to participate in the diabetes education program.

b.

Assess the patients perception of what it means to have diabetes mellitus.

c.

Demonstrate how to check glucose using capillary blood glucose monitoring.

d.

Discuss the need for the patient to actively participate in diabetes management.

Answer 20

ANS: B

Before planning teaching, the nurse should assess the patients interest in and ability to self-manage the diabetes. After assessing the patient, the other nursing actions may be appropriate, but planning needs to be individualized to each patient.

Question 21

21. An unresponsive patient with type 2 diabetes is brought to the emergency department and diagnosed with hyperosmolar hyperglycemic syndrome (HHS). The nurse will anticipate the need to

a.

give a bolus of 50% dextrose.

b.

insert a large-bore IV catheter.

c.

initiate oxygen by nasal cannula.

d.

administer glargine (Lantus) insulin.

Answer 21

ANS: B

HHS is initially treated with large volumes of IV fluids to correct hypovolemia. Regular insulin is administered, not a long-acting insulin. There is no indication that the patient requires oxygen. Dextrose solutions will increase the patients blood glucose and would be contraindicated.

Question 22

22. A 26-year-old female with type 1 diabetes develops a sore throat and runny nose after caring for her sick toddler. The patient calls the clinic for advice about her symptoms and a blood glucose level of 210 mg/dL despite taking her usual glargine (Lantus) and lispro (Humalog) insulin. The nurse advises the patient to

a.

use only the lispro insulin until the symptoms are resolved.

b.

limit intake of calories until the glucose is less than 120 mg/dL.

c.

monitor blood glucose every 4 hours and notify the clinic if it continues to rise.

d.

decrease intake of carbohydrates until glycosylated hemoglobin is less than 7%.

Answer 22

ANS: C

Infection and other stressors increase blood glucose levels and the patient will need to test blood glucose frequently, treat elevations appropriately with lispro insulin, and call the health care provider if glucose levels continue to be elevated. Discontinuing the glargine will contribute to hyperglycemia and may lead to diabetic ketoacidosis (DKA). Decreasing carbohydrate or caloric intake is not appropriate because the patient will need more calories when ill. Glycosylated hemoglobin testing is not used to evaluate short-term alterations in blood glucose.

Question 23

23. The health care provider suspects the Somogyi effect in a 50-year-old patient whose 6:00 AM blood glucose is 230 mg/dL. Which action will the nurse teach the patient to take?

a.

Avoid snacking at bedtime.

b.

Increase the rapid-acting insulin dose.

c.

Check the blood glucose during the night

d.

Administer a larger dose of long-acting insulin.

Answer 23

ANS: C

If the Somogyi effect is causing the patients increased morning glucose level, the patient will experience hypoglycemia between 2:00 and 4:00 AM. The dose of insulin will be reduced, rather than increased. A bedtime snack is used to prevent hypoglycemic episodes during the night.

Question 24

24. Which action should the nurse take after a 36-year-old patient treated with intramuscular glucagon for hypoglycemia regains consciousness?

a.

Assess the patient for symptoms of hyperglycemia.

b.

Give the patient a snack of peanut butter and crackers.

c.

Have the patient drink a glass of orange juice or nonfat milk.

d.

Administer a continuous infusion of 5% dextrose for 24 hours.

Answer 24

ANS: B

Rebound hypoglycemia can occur after glucagon administration, but having a meal containing complex carbohydrates plus protein and fat will help prevent hypoglycemia. Orange juice and nonfat milk will elevate blood glucose rapidly, but the cheese and crackers will stabilize blood glucose. Administration of IV glucose might be used in patients who were unable to take in nutrition orally. The patient should be assessed for symptoms of hypoglycemia after glucagon administration.

Question 25

25. Which question during the assessment of a diabetic patient will help the nurse identify autonomic neuropathy?

a.

Do you feel bloated after eating?

b.

Have you seen any skin changes?

c.

Do you need to increase your insulin dosage when you are stressed?

d.

Have you noticed any painful new ulcerations or sores on your feet?

Answer 25

ANS: A

Autonomic neuropathy can cause delayed gastric emptying, which results in a bloated feeling for the patient. The other questions are also appropriate to ask but would not help in identifying autonomic neuropathy.

Question 26

26. Which information will the nurse include in teaching a female patient who has peripheral arterial disease, type 2 diabetes, and sensory neuropathy of the feet and legs?

a.

Choose flat-soled leather shoes.

b.

Set heating pads on a low temperature.

c.

Use callus remover for corns or calluses.

d.

Soak feet in warm water for an hour each day.

Answer 26

ANS: A

The patient is taught to avoid high heels and that leather shoes are preferred. The feet should be washed, but not soaked, in warm water daily. Heating pad use should be avoided. Commercial callus and corn removers should be avoided. The patient should see a specialist to treat these problems.

Question 27

27. Which finding indicates a need to contact the health care provider before the nurse administers metformin (Glucophage)?

a.

The patients blood glucose level is 174 mg/dL.

b.

The patient has gained 2 lb (0.9 kg) since yesterday.

c.

The patient is scheduled for a chest x-ray in an hour.

d.

The patients blood urea nitrogen (BUN) level is 52 mg/dL.

Answer 27

ANS: D

The BUN indicates possible renal failure, and metformin should not be used in patients with renal failure. The other findings are not contraindications to the use of metformin.

Question 28

28. A diabetic patient who has reported burning foot pain at night receives a new prescription. Which information should the nurse teach the patient about amitriptyline (Elavil)?

a.

Amitriptyline decreases the depression caused by your foot pain.

b.

Amitriptyline helps prevent transmission of pain impulses to the brain.

c.

Amitriptyline corrects some of the blood vessel changes that cause pain.

d.

Amitriptyline improves sleep and makes you less aware of nighttime pain.

Answer 28

ANS: B

Tricyclic antidepressants decrease the transmission of pain impulses to the spinal cord and brain. Tricyclic antidepressants also improve sleep quality and are used for depression, but that is not the major purpose for their use in diabetic neuropathy. The blood vessel changes that contribute to neuropathy are not affected by tricyclic antidepressants.

Question 29

29. Which information is most important for the nurse to report to the health care provider before a patient with type 2 diabetes is prepared for a coronary angiogram?

a.

The patients most recent HbA1C was 6.5%.

b.

The patients admission blood glucose is 128 mg/dL.

c.

The patient took the prescribed metformin (Glucophage) today.

d.

The patient took the prescribed captopril (Capoten) this morning.

Answer 29

ANS: C

To avoid lactic acidosis, metformin should be discontinued a day or 2 before the coronary arteriogram and should not be used for 48 hours after IV contrast media are administered. The other patient data will also be reported but do not indicate any need to reschedule the procedure.

Question 30

30. Which action by a patient indicates that the home health nurses teaching about glargine and regular insulin has been successful?

a.

The patient administers the glargine 30 minutes before each meal.

b.

The patients family prefills the syringes with the mix of insulins weekly.

c.

The patient draws up the regular insulin and then the glargine in the same syringe.

d.

The patient disposes of the open vials of glargine and regular insulin after 4 weeks.

Answer 30

ANS: D

Insulin can be stored at room temperature for 4 weeks. Glargine should not be mixed with other insulins or prefilled and stored. Short-acting regular insulin is administered before meals, while glargine is given once daily.

Question 31

31. A 26-year-old patient with diabetes rides a bicycle to and from work every day. Which site should the nurse teach the patient to administer the morning insulin?

a.

thigh.

b.

buttock.

c.

abdomen.

d.

upper arm.

Answer 31

ANS: C

Patients should be taught not to administer insulin into a site that will be exercised because exercise will increase the rate of absorption. The thigh, buttock, and arm are all exercised by riding a bicycle.

Question 32

32. The nurse is interviewing a new patient with diabetes who receives rosiglitazone (Avandia) through a restricted access medication program. What is most important for the nurse to report immediately to the health care provider?

a.

The patients blood pressure is 154/92.

b.

The patient has a history of emphysema.

c.

The patients blood glucose is 86 mg/dL.

d.

The patient has chest pressure when walking.

Answer 32

ANS: D

Rosiglitazone can cause myocardial ischemia. The nurse should immediately notify the health care provider and expect orders to discontinue the medication. There is no urgent need to discuss the other data with the health care provider.

Question 33

33. The nurse is taking a health history from a 29-year-old pregnant patient at the first prenatal visit. The patient reports no personal history of diabetes but has a parent who is diabetic. Which action will the nurse plan to take first?

a.

Teach the patient about administering regular insulin.

b.

Schedule the patient for a fasting blood glucose level.

c.

Discuss an oral glucose tolerance test for the twenty-fourth week of pregnancy.

d.

Provide teaching about an increased risk for fetal problems with gestational diabetes.

Answer 33

ANS: B

Patients at high risk for gestational diabetes should be screened for diabetes on the initial prenatal visit. An oral glucose tolerance test may also be used to check for diabetes, but it would be done before the twenty-fourth week. The other actions may also be needed (depending on whether the patient develops gestational diabetes), but they are not the first actions that the nurse should take.

Question 34

34. A 27-year-old patient admitted with diabetic ketoacidosis (DKA) has a serum glucose level of 732 mg/dL and serum potassium level of 3.1 mEq/L. Which action prescribed by the health care provider should the nurse takefirst?

a.

Place the patient on a cardiac monitor.

b.

Administer IV potassium supplements.

c.

Obtain urine glucose and ketone levels.

d.

Start an insulin infusion at 0.1 units/kg/hr.

Answer 34

ANS: A

Hypokalemia can lead to potentially fatal dysrhythmias such as ventricular tachycardia and ventricular fibrillation, which would be detected with electrocardiogram (ECG) monitoring. Because potassium must be infused over at least 1 hour, the nurse should initiate cardiac monitoring before infusion of potassium. Insulin should not be administered without cardiac monitoring because insulin infusion will further decrease potassium levels. Urine glucose and ketone levels are not urgently needed to manage the patients care.

Question 35

35. A 54-year-old patient is admitted with diabetic ketoacidosis. Which admission order should the nurse implement first?

a.

Infuse 1 liter of normal saline per hour.

b.

Give sodium bicarbonate 50 mEq IV push.

c.

Administer regular insulin 10 U by IV push.

d.

Start a regular insulin infusion at 0.1 units/kg/hr.

Answer 35

ANS: A

The most urgent patient problem is the hypovolemia associated with diabetic ketoacidosis (DKA), and the priority is to infuse IV fluids. The other actions can be done after the infusion of normal saline is initiated.

Question 36

36. A patient who was admitted with diabetic ketoacidosis secondary to a urinary tract infection has been weaned off an insulin drip 30 minutes ago. The patient reports feeling lightheaded and sweaty. Which action should the nurse take first?

a.

Infuse dextrose 50% by slow IV push.

b.

Administer 1 mg glucagon subcutaneously.

c.

Obtain a glucose reading using a finger stick.

d.

Have the patient drink 4 ounces of orange juice.

Answer 36

ANS: C

The patients clinical manifestations are consistent with hypoglycemia and the initial action should be to check the patients glucose with a finger stick or order a stat blood glucose. If the glucose is low, the patient should ingest a rapid-acting carbohydrate, such as orange juice. Glucagon or dextrose 50% might be given if the patients symptoms become worse or if the patient is unconscious.

Question 37

37. A female patient is scheduled for an oral glucose tolerance test. Which information from the patients health history is most important for the nurse to communicate to the health care provider?

a.

The patient uses oral contraceptives.

b.

The patient runs several days a week.

c.

The patient has been pregnant three times.

d.

The patient has a family history of diabetes.

Answer 37

ANS: A

Oral contraceptive use may falsely elevate oral glucose tolerance test (OGTT) values. Exercise and a family history of diabetes both can affect blood glucose but will not lead to misleading information from the OGTT. History of previous pregnancies may provide informational about gestational glucose tolerance, but will not lead to misleading information from the OGTT.

Question 38

38. Which laboratory value reported to the nurse by the unlicensed assistive personnel (UAP) indicates the most urgent need for the nurses assessment of the patient?

a.

Bedtime glucose of 140 mg/dL

b.

Noon blood glucose of 52 mg/dL

c.

Fasting blood glucose of 130 mg/dL

d.

2-hr postprandial glucose of 220 mg/dL

Answer 38

ANS: B

The nurse should assess the patient with a blood glucose level of 52 mg/dL for symptoms of hypoglycemia and give the patient a carbohydrate-containing beverage such as orange juice. The other values are within an acceptable range or not immediately dangerous for a diabetic patient.

Question 39

39. When a patient with type 2 diabetes is admitted for a cholecystectomy, which nursing action can the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)?

a.

Communicate the blood glucose level and insulin dose to the circulating nurse in surgery.

b.

Discuss the reason for the use of insulin therapy during the immediate postoperative period.

c.

Administer the prescribed lispro (Humalog) insulin before transporting the patient to surgery.

d.

Plan strategies to minimize the risk for hypoglycemia or hyperglycemia during the postoperative period.

Answer 39

ANS: C

LPN/LVN education and scope of practice includes administration of insulin. Communication about patient status with other departments, planning, and patient teaching are skills that require RN education and scope of practice.

Question 40

40. An active 28-year-old male with type 1 diabetes is being seen in the endocrine clinic. Which finding may indicate the need for a change in therapy?

a.

Hemoglobin A1C level 6.2%

b.

Blood pressure 146/88 mmHg

c.

Heart rate at rest 58 beats/minute

d.

High density lipoprotein (HDL) level 65 mg/dL

Answer 40

ANS: B

To decrease the incidence of macrovascular and microvascular problems in patients with diabetes, the goal blood pressure is usually 130/80. An A1C less than 6.5%, a low resting heart rate (consistent with regular aerobic exercise in a young adult), and an HDL level of 65 mg/dL all indicate that the patients diabetes and risk factors for vascular disease are well controlled.

Question 41

41. A 34-year-old has a new diagnosis of type 2 diabetes. The nurse will discuss the need to schedule a dilated eye exam

a.

every 2 years.

b.

as soon as possible.

c.

when the patient is 39 years old.

d.

within the first year after diagnosis.

Answer 41

ANS: B

Because many patients have some diabetic retinopathy when they are first diagnosed with type 2 diabetes, a dilated eye exam is recommended at the time of diagnosis and annually thereafter. Patients with type 1 diabetes should have dilated eye exams starting 5 years after they are diagnosed and then annually.

Question 42

42. After the nurse has finished teaching a patient who has a new prescription for exenatide (Byetta), which patient statement indicates that the teaching has been effective?

a.

I may feel hungrier than usual when I take this medicine.

b.

I will not need to worry about hypoglycemia with the Byetta.

c.

I should take my daily aspirin at least an hour before the Byetta.

d.

I will take the pill at the same time I eat breakfast in the morning.

Answer 42

ANS: C

Since exenatide slows gastric emptying, oral medications should be taken at least an hour before the exenatide to avoid slowing absorption. Exenatide is injected and increases feelings of satiety. Hypoglycemia can occur with this medication.

Question 43

43. A few weeks after an 82-year-old with a new diagnosis of type 2 diabetes has been placed on metformin (Glucophage) therapy and taught about appropriate diet and exercise, the home health nurse makes a visit. Which finding by the nurse is most important to discuss with the health care provider?

a.

Hemoglobin A1C level is 7.9%.

b.

Last eye exam was 18 months ago.

c.

Glomerular filtration rate is decreased.

d.

Patient has questions about the prescribed diet.

Answer 43

ANS: C

The decrease in renal function may indicate a need to adjust the dose of metformin or change to a different medication. In older patients, the goal for A1C may be higher in order to avoid complications associated with hypoglycemia. The nurse will plan on scheduling the patient for an eye exam and addressing the questions about diet, but the biggest concern is the patients decreased renal function.

Question 44

44. The nurse has administered 4 oz of orange juice to an alert patient whose blood glucose was 62 mg/dL. Fifteen minutes later, the blood glucose is 67 mg/dL. Which action should the nurse take next?

a.

Give the patient 4 to 6 oz more orange juice.

b.

Administer the PRN glucagon (Glucagon) 1 mg IM.

c.

Have the patient eat some peanut butter with crackers.

d.

Notify the health care provider about the hypoglycemia.

Answer 44

ANS: A

The rule of 15 indicates that administration of quickly acting carbohydrates should be done 2 to 3 times for a conscious patient whose glucose remains less than 70 mg/dL before notifying the health care provider. More complex carbohydrates and fats may be used once the glucose has stabilized. Glucagon should be used if the patients level of consciousness decreases so that oral carbohydrates can no longer be given.

Question 45

45. Which nursing action can the nurse delegate to unlicensed assistive personnel (UAP) who are working in the diabetic clinic?

a.

Measure the ankle-brachial index.

b.

Check for changes in skin pigmentation.

c.

Assess for unilateral or bilateral foot drop.

d.

Ask the patient about symptoms of depression.

Answer 45

ANS: A

Checking systolic pressure at the ankle and brachial areas and calculating the ankle-brachial index is a procedure that can be done by UAP who have been trained in the procedure. The other assessments require more education and critical thinking and should be done by the registered nurse (RN).

Question 46

46. After change-of-shift report, which patient will the nurse assess first?

a.

19-year-old with type 1 diabetes who was admitted with possible dawn phenomenon

b.

35-year-old with type 1 diabetes whose most recent blood glucose reading was 230 mg/dL

c.

60-year-old with hyperosmolar hyperglycemic syndrome who has poor skin turgor and dry oral mucosa

d.

68-year-old with type 2 diabetes who has severe peripheral neuropathy and complains of burning foot pain

Answer 46

ANS: C

The patients diagnosis of HHS and signs of dehydration indicate that the nurse should rapidly assess for signs of shock and determine whether increased fluid infusion is needed. The other patients also need assessment and intervention but do not have life-threatening complications.

Question 47

47. After change-of-shift report, which patient should the nurse assess first?

a.

19-year-old with type 1 diabetes who has a hemoglobin A1C of 12%

b.

23-year-old with type 1 diabetes who has a blood glucose of 40 mg/dL

c.

40-year-old who is pregnant and whose oral glucose tolerance test is 202 mg/dL

d.

50-year-old who uses exenatide (Byetta) and is complaining of acute abdominal pain

Answer 47

ANS: B

Because the brain requires glucose to function, untreated hypoglycemia can cause unconsciousness, seizures, and death. The nurse will rapidly assess and treat the patient with low blood glucose. The other patients also have symptoms that require assessments and/or interventions, but they are not at immediate risk for life-threatening complications.

Question 48

1. To monitor for complications in a patient with type 2 diabetes, which tests will the nurse in the diabetic clinic schedule at least annually (select all that apply)?

a.

Chest x-ray

b.

Blood pressure

c.

Serum creatinine

d.

Urine for microalbuminuria

e.

Complete blood count (CBC)

f.

Monofilament testing of the foot

Answer 48

ANS: B, C, D, F

Blood pressure, serum creatinine, urine testing for microalbuminuria, and monofilament testing of the foot are recommended at least annually to screen for possible microvascular and macrovascular complications of diabetes. Chest x-ray and CBC might be ordered if the diabetic patient presents with symptoms of respiratory or infectious problems but are not routinely included in screening.

Question 49

1. In which order will the nurse take these steps to prepare NPH 20 units and regular insulin 2 units using the same syringe? (Put a comma and a space between each answer choice [A, B, C, D, E]).
   a. Rotate NPH vial.
   b. Withdraw regular insulin.
   c. Withdraw 20 units of NPH.
   d. Inject 20 units of air into NPH vial.
   e. Inject 2 units of air into regular insulin vial.

Answer 49

ANS:

A, D, E, B, C

When mixing regular insulin with NPH, it is important to avoid contact between the regular insulin and the additives in the NPH that slow the onset, peak, and duration of activity in the longer-acting insulin.