Chapter 52

Question 1

The nurse is caring for a client with newly diagnosed type 2 diabetes mellitus who asks the nurse what “type 2” means in relation to diabetes. Which of the following statements by the nurse about type 2 diabetes is correct?
a. Insulin is not used to control blood glucose in clients with type 2 diabetes.
b. Complications of type 2 diabetes are less serious than those of type 1 diabetes.
c. Type 2 diabetes is usually diagnosed when the client is admitted with a
hyperglycemic coma.
d. Changes in diet and exercise may be sufficient to control blood glucose levels in
type 2 diabetes.

Answer 1

D
For some clients, changes in lifestyle are sufficient for 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 client develops complications such as frequent yeast infections.

Question 2

The nurse is assessing a client for diabetes at a clinic who has a fasting plasma glucose level of 6.7 mmol/L. Which of the following information should the nurse include in the plan of care?
a. Self-monitoring of blood glucose.
b. Use of low doses of regular insulin.
c. Lifestyle changes to lower blood glucose.
d. Effects of oral hypoglycemic medications.

Answer 2

ANS: C
The client’s impaired fasting glucose indicates prediabetes and the client should be counselled about lifestyle changes to prevent the development of type 2 diabetes. The client with prediabetes does not require insulin or the oral hypoglycemics for glucose control and does not need to self-monitor blood glucose.

Question 3

Which of the following actions by a client with type 1 diabetes indicates that the nurse should implement teaching about exercise and glucose control?
a. The client always carries hard candies when engaging in exercise.
b. The client goes for a vigorous walk when the glucose is 11.1 mmol/L.
c. The client has a peanut butter sandwich before going for a bicycle ride.
d. The client increases daily exercise when ketones are present in the urine.

Answer 3

D

Question 4

The nurse is assessing a client who is experiencing the onset of symptoms of type 1 diabetes. Which of the following questions is best for the nurse to ask?
a. “Have you lost any weight lately?”
b. “How long have you felt anorexic?”
c. “Is your urine unusually dark coloured?”
d. “Do you crave fluids containing sugar?

Answer 4

ANS: A
Weight loss occurs because the body is no longer able to absorb glucose and starts to break down protein and fat for energy. The client 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

. To evaluate the effectiveness of treatment for a client with type 2 diabetes who is scheduled for a follow-up visit in the clinic, which of the following tests will the nurse plan to schedule for the client?
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 (Hb A1C) test shows the overall control of glucose over 90–120 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

The nurse is caring for a client who has just been diagnosed with type 2 diabetes and has a nursing diagnosis of imbalanced nutrition: more than body requirements. Which of the following client goals is most important?
a. The client will have a glycosylated hemoglobin level of less than 7%.
b. The client will have a diet and exercise plan that results in weight loss.
c. The client will choose a diet that distributes calories throughout the day.
d. The client will state the reasons for eliminating simple sugars in the diet.

Answer 6

A

Question 7

A client who has type 1 diabetes plans to take a swimming class daily at 1:00 P.M. Which of the following instructions should the nurse teach to the client?
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 client will need to monitor glucose carefully to determine the need for changes in diet and insulin administration. Because exercise tends to decrease blood glucose, clients 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

The nurse is caring for a client with newly diagnosed type 1 diabetes who has received diet instruction. Which of the following client statements indicate a need for additional instruction?
a. “I may 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 may eat whatever I want, as long as I use enough insulin to cover the calories.”
d. “I will eat meals as scheduled, even if I am not hungry, to prevent hypoglycemia.”

Answer 8

ANS: C
Most clients with type 1 diabetes need to plan diet choices very carefully. Clients 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 client statements are correct and indicate good understanding of the diet instruction.

Question 9

Which of the following actions is most important for the nurse to take in order to assist a client with diabetes to engage in moderate daily exercise?
a. Remind the client that exercise will improve self-esteem.
b. Determine what type of exercise activities the client enjoys.
c. Give the client a list of activities that are moderate in intensity.
d. Teach the client about the effects of exercise on glucose level.

Answer 9

B

Question 10

The nurse is teaching the client to administer a dose of 10 units of regular insulin and 28 units of NPH insulin. Which of the following statements by the client indicates a need for additional instruction?
a. “I need to rotate injection sites among my arms, legs, and abdomen each day.”
b. “I will 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

A

Question 11

After the nurse has finished teaching a client about self-administration of the prescribed aspart insulin, which of the following client actions indicate good understanding of the teaching?
a. The client avoids injecting the insulin into the upper abdominal area.
b. The client cleans the skin with soap and water before insulin administration.
c. The client places the insulin back in the freezer after administering the prescribed
insulin dose.
d. The client pushes the plunger down and immediately removes the syringe from the
injection site.

Answer 11

ANS: B
The use of an alcohol swab on the site before self-injection is no longer recommended. Routine hygiene such as washing with soap and rinsing with water is adequate. Insulin should not be frozen. The client 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 injectio

Question 12

The nurse is caring for a client who received aspart insulin at 8:00 A.M. Which of the following times is most important for the nurse to monitor for symptoms of hypoglycemia?
a. 9:00 A.M.
b. 11:30 A.M.
c. 4:00 P.M.
d. 8:00 P.M.

Answer 12

ANS: A
The rapid-acting insulins peak in 60–90 minutes. The client is not at a high risk for hypoglycemia at the other listed times although hypoglycemia may occur.

Question 13

Which of the following client actions indicate a good understanding of the nurse’s teaching about the use of an insulin pump?
a. The client changes the site for the insertion site every week.
b. The client programs the pump to deliver an insulin bolus after eating.
c. The client takes the pump off at bedtime and starts it again each morning.
d. The client states that diet will be less flexible when using the insulin pump.

Answer 13

ANS: B
In addition to the basal rate of insulin infusion, the client 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

The nurse is teaching about meal coverage to a client with diabetes who has just started on intensive insulin therapy. Which of the following types of insulin should the nurse discuss with the client?
a. Glargine
b. Lispro
c. Detemir
d. NPH

Answer 14

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

Question 15

Which of the following information should the nurse include when teaching a client who has type 2 diabetes about glyburide?
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

B

Question 16

The nurse has completed teaching a client with type 2 diabetes about taking gliclazide. Which of the following client statements indicate a need for additional teaching?
a. “Other medications besides the gliclazide may affect my blood sugar.”
b. “If I overeat at a meal, I will still take just the usual dose of medication.”
c. “When I become ill, I may have to take insulin to control my blood sugar.”
d. “My diabetes is not as likely to cause complications as if I needed to take insulin.”

Answer 16

ANS: D
The client should understand that type 2 diabetes places the client 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 gliclazide

Question 17

A client with type 2 diabetes that is well-controlled with metformin develops an allergic rash to an antibiotic and the health care provider prescribes prednisone. Which of the following information should the nurse anticipate while the client is taking the prednisone?
a. A diet higher in calories
b. Administration of insulin
c. Development of acute hypoglycemia
d. Appearance of a rash caused by metformin–prednisone interactions.

Answer 17

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

Question 18

The nurse is caring for a client with diabetes who received 34 units of NPH insulin at 7:00 A.M. and is away from the nursing unit, awaiting diagnostic testing when lunch trays are distributed. Which of the following actions is best to prevent hypoglycemia?
a. Save the lunch tray to be provided upon the client’s return to the unit.
b. Call the diagnostic testing area and ask that a 5% dextrose IV be started.
c. Ensure that the client drinks a glass of orange juice at noon in the diagnostic
testing area.
d. Request that the client be returned to the unit to eat lunch if testing will not be
completed promptly.

Answer 18

ANS: D
Consistency for mealtimes assists with regulation of blood glucose, so the best option is for the client 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 client. A glass of juice will keep the client from becoming hypoglycemic but will cause a rapid rise in blood glucose because of the rapid absorption of the simpl

Question 19

The nurse is assessing a client’s technique of self-monitoring of blood glucose (SMBG) as part of diabetes management. Which of the following actions indicate a need for further teaching?
a. Washes the puncture site using soap and warm water.
b. Chooses a puncture site in the centre of the finger pad.
c. Hangs the arm down for a minute before puncturing the site.
d. Says the result of 6.1 mmol/L indicates good blood sugar control.

Answer 19

ANS: B
The client is taught to choose a puncture site at the side of the finger pad. The other client actions indicate that teaching has been effective

Question 20

Which of the following actions should the nurse take first when teaching a client who is newly diagnosed with type 2 diabetes about home management of the disease?
a. Ask the client’s family to participate in the diabetes education program.
b. Assess the client’s 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 client to participate actively in diabetes management.

Answer 20

ANS: B
Before planning education, the nurse should assess the client’s interest in and ability to self-manage the diabetes. After assessing the client, the other nursing actions may be appropriate, but planning needs to be individualized to each client

Question 21

A diagnosis of hyperglycemic hyperosmolar state (HHS) is made for a client with type 2 diabetes who is brought to the emergency department in an unresponsive state. Which of the following actions should the nurse anticipate?
a. Give 50% dextrose as a bolus
b. Insert a large-bore IV catheter
c. Initiate oxygen by nasal cannula
d. Administer glargine insulin

Answer 21

B

Question 22

A client with type 1 diabetes who is on glargine and lispro insulin has called the clinic to report symptoms of a sore throat, cough, fever, and blood glucose level of 11.7 mmol/L. Which of the following information should the nurse tell the client?
a. Use only the lispro insulin until the symptoms of infection are resolved.
b. Monitor blood glucose every 4 hours and notify the clinic if it continues to rise.
c. Decrease intake of carbohydrates until glycosylated hemoglobin is less than 7%.
d. Limit intake of calorie-containing liquids until the glucose is less than 6.7 mmol/L.

Answer 22

ANS: B
Infection and other stressors increase blood glucose levels and the client 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 client will need more calories when ill. Glycosylated hemoglobins are not used to test for short-term alterations in blood glucose

Question 23

The health care provider suspects the Somogyi effect in a client whose 7:00 A.M. blood glucose is 12.2 mmol/L. Which action should the nurse plan to take?
a. Check the client’s blood glucose at 3:00 A.M.
b. Administer a larger dose of long-acting insulin.
c. Educate about the need to increase the rapid-acting insulin dose.
d. Remind the client about the need to avoid snacking at bedtime.

Answer 23

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

Question 24

The nurse administers intramuscular glucagon to a client who is unresponsive for treatment of hypoglycemia. Which of the following actions should the nurse take after the client regains consciousness?
a. Assess the client for symptoms of hyperglycemia.
b. Give the client a snack of crackers and peanut butter.
c. Have the client 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. A starch snack is recommended. Orange juice and nonfat milk will elevate blood sugar rapidly, but the cheese and crackers will stabilize blood sugar. Administration of glucose intravenously might be used in clients who were unable to take in nutrition orally. The client should be assessed for symptoms of hypoglycemia after glucagon administration

Question 25

Which of the following questions by the nurse will help identify autonomic neuropathy in a client with diabetes? a. “Have you observed any recent skin changes?” b. “Do you notice any bloating feeling after eating?” 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: B Autonomic neuropathy can cause delayed gastric emptying, which results in a bloated feeling for the client. The other questions are also appropriate to ask, but would not help in identifying autonomic neuropathy.

Question 26

The nurse is caring for a client with type 2 diabetes who has sensory neuropathy of the feet and legs and peripheral arterial disease. Which of the following information will the nurse include in client teaching? a. Choose flat-soled leather shoes. b. Set heating pads on a low temperature. c. Buy callus remover for corns or calluses. d. Soak the feet in warm water for an hour every day.

Answer 26

ANS: A The client 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 client should see a specialist to treat these problems

Question 27

The nurse obtains the following information about a client before administration of metformin. Which of the following findings indicate a need to contact the health care provider before giving the metformin? a. The client’s blood glucose level is 9.2 mmol/L. b. The client’s blood urea nitrogen (BUN) level is 21.4 mmol/L. c. The client is scheduled for a chest x-ray in an hour. d. The client has gained 1 kg since yesterday.

Answer 27

ANS: B The BUN indicates impending renal failure and metformin should not be used in clients with renal or hepatic impairment. The other findings are not contraindications to the use of metformin.

Question 28

Amitriptyline is prescribed for a diabetic client who has burning foot pain at night. Which of the following information should the nurse include when teaching the client about the new medication? a. Amitriptyline will decrease the depression caused by your foot pain. b. Amitriptyline will correct some of the blood vessel changes that cause pain. c. Amitriptyline will improve sleep and make you less aware of nighttime pain. d. Amitriptyline will help prevent the transmission of pain impulses to the brain.

Answer 28

ANS: D Tricyclic antidepressants decrease the transmission of pain impulses to the spinal cord and brain. Tricyclics 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 tricyclics.

Question 29

The nurse is admitting a client with type 2 diabetes for an outpatient coronary arteriogram. Which of the following information obtained by the nurse is most important to report to the health care provider before the procedure? a. The client’s admission blood glucose is 7.1 mmol/L. b. The client’s most recent Hb A1C was 6.5%. c. The client took the prescribed metformin today. d. The client took the prescribed captopril 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 client data will also be reported but do not indicate any need to reschedule the procedure.

Question 30

The home health nurse is providing teaching to a client and family about how to use glargine and regular insulin safely. Which of the following actions by the client indicates that the teaching has been successful? a. The client administers the glargine 30–45 minutes before eating each meal. b. The client’s family fills the syringes weekly and stores them in the refrigerator. c. The client draws up the regular insulin and then the glargine in the same syringe. d. The client disposes of the open vials of glargine and regular insulin after 4 weeks.

Answer 30

D

Question 31

The nurse is teaching a client with diabetes who rides a bicycle to work every day about morning administration of insulin. Which of the following sites should the nurse tell the client to use to administer the morning insulin? a. Arm b. Thigh c. Buttock d. Abdomen

Answer 31

ANS: D Clients 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

Which of the following information about a client who receives rosiglitazone is most important for the nurse to report immediately to the health care provider? a. The client’s blood pressure is 154/92. b. The client has a history of emphysema. c. The client’s noon blood glucose is 4.7 mmol/L. d. The client has chest pressure when ambulating.

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

The nurse is preparing to assess a client who is pregnant and has no personal history of diabetes but does have a parent with diabetes. Which of the following actions should the nurse plan to take on this initial prenatal visit? a. Teach about appropriate use of regular insulin. b. Discuss the need for a fasting blood glucose level. c. Schedule an oral glucose tolerance test for the twenty-fourth week of pregnancy. d. Provide education about increased risk for fetal problems with gestational diabetes.

Answer 33

ANS: B Clients 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 client develops gestational diabetes), but they are not the first actions that the nurse should take.

Question 34

The nurse is admitting a client with diabetic ketoacidosis (DKA) who has a serum potassium level of 2.9 mmol/L. Which of the following actions prescribed by the health care provider should the nurse take first? a. Infuse regular insulin at 20 units/hour. b. Place the client on a cardiac monitor. c. Administer IV potassium supplements. d. Obtain urine glucose and ketone levels

Answer 34

ANS: B Hypokalemia can lead to potentially fatal dysrhythmias such as ventricular tachycardia and ventricular fibrillation, which would be detected with ECG monitoring. Since 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, since insulin infusion will further decrease potassium levels. Urine glucose and ketone levels are not urgently needed to manage the client’s care.

Question 35

The nurse is admitting a client with diabetic ketoacidosis. Which of the following prescriptions should the nurse implement first? a. Administer regular IV insulin 30 units. b. Infuse 1 L of normal saline per hour. c. Give sodium bicarbonate 50 mEq IV push. d. Start an infusion of regular insulin at 50 units/hour.

Answer 35

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

Question 36

The nurse is assessing a client who is recovering from an episode of diabetic ketoacidosis and the client reports feeling anxious, nervous, and sweaty. Which of the following actions should the nurse take first? a. Administer 1 mg glucagon subcutaneously. b. Obtain a glucose reading using a finger stick. c. Have the client drink 120 mL of orange juice. d. Give the scheduled dose of lispro insulin.

Answer 36

ANS: B The client’s clinical manifestations are consistent with hypoglycemia and the initial action should be to check the client’s glucose with a finger stick or order a stat blood glucose. If the glucose is low, the client should ingest a rapid-acting carbohydrate, such as orange juice. Glucagon might be given if the client’s symptoms become worse or if the client is unconscious. Administration of lispro would drop the client’s glucose furth

Question 37

Which of the following client teaching information is most important for the nurse to communicate to a client with gestational diabetes? a. Delivery will not affect blood glucose levels. b. Exercise should be avoided in the last month of pregnancy. c. Monitoring of blood glucose can stop as soon as the baby is delivered. d. A postpartum OGTT will be done at 2 months.

Answer 37

ANS: D Women should be screened postpartum to determine their glucose status. The 2008 CDA guidelines recommend a 75-g oral glucose tolerance test (OGTT) be done between 6 weeks and 6 months postpartum. Delivery may affect blood glucose levels. Exercise is not to be avoided. Monitoring of blood glucose will continue into the postpartum period until levels are within normal limits.

Question 38

Which of the following laboratory values, noted by the nurse when reviewing the chart of a hospitalized client with diabetes, indicates the need for rapid assessment of the client? a. Hb A1C of 5.8% b. Noon blood glucose of 2.9 mmol/L c. Hb A1Cof 6.9% d. Fasting blood glucose of 7.2 mmol/L

Answer 38

ANS: B The nurse should assess the client with a blood glucose level of 2.9 mmol/L for symptoms of hypoglycemia as the normal range is 4–6 mmol/L. The other values are within an acceptable range for a diabetic client.