MS - Diabetes

Question 1

In addition to promoting the transport of glucose from the blood into the cell, what does insulin do?

a. Enhances the breakdown of adipose tissue for energy
b. Stimulates hepatic glycogenolysis and gluconeogenesis
c. Prevents the transport of triglycerides into adipose tissue
d. Accelerates the transport of amino acids into cells and their synthesis into protein

Answer 1

d. Accelerates the transport of amino acids into cells and their synthesis into protein

Insulin is an anabolic hormone that is responsible for growth, repair, and storage. It facilitates movement of amino acids into cells, synthesis of protein, storage of glucose as glycogen, and deposition of triglycerides and lipids as fat into adipose tissue. Glucagon is responsible for hepatic glycogenolysis and gluconeogenesis. Fat is used for energy when glucose levels are depleted.

Question 2

Which tissues require insulin to enable movement of glucose into the tissue cells (select all that apply)?

a. Liver
b. Brain
c. Adipose
d. Blood cells
e. Skeletal muscle

Answer 2

c. Adipose
e. Skeletal muscle

Adipose tissue and skeletal muscle require insulin to allow the transport of glucose into the cells. Brain, liver, and blood cells require adequate glucose supply for normal function but do not depend directly on insulin for glucose transport.

Question 3

Why are the hormones cortisol, glucagon, epinephrine, and growth hormone referred to as counter regulatory hormones?

a. Decrease glucose production
b. Stimulate glucose output by the liver
c. Increase glucose transport into the cells
d. Independently regulate glucose level in the blood

Answer 3

b. Stimulate glucose output by the liver

The counter regulatory hormones have the opposite effect of insulin by stimulating glucose production and output by the liver and by decreasing glucose transport into the cells. The counter regulatory hormones and insulin together regulate the blood glucose level.

Question 4

What characterizes type 2 diabetes (select all that apply)?

a. B-Cell exhaustion
b. Insulin resistance
c. Genetic predisposition
d. Altered production of adipokines
e. Inherited defect in insulin receptors
f. Inappropriate glucose production by the liver

Answer 4

(All of the above.)

a. B-Cell exhaustion
b. Insulin resistance
c. Genetic predisposition
d. Altered production of adipokines
e. Inherited defect in insulin receptors
f. Inappropriate glucose production by the liver

Type 2 diabetes is characterized by insulin resistance, B-cell exhaustion, altered production of adipokines, genetic predisposition, inherited defect in insulin receptors, and inappropriate glucose production by the liver.

Question 5

Which laboratory result would indicate that the patient has prediabetes?

a. Glucose tolerance result of 132 mg/dL
b. Glucose tolerance result of 240 mg/dL
c. Fasting blood glucose result of 80 mg/dL
d. Fasting blood glucose of 120 mg/dL

Answer 5

d. Fasting blood glucose of 120 mg/dL

Prediabetes is defined as impaired glucose tolerance and impaired fasting glucose or both. Fasting blood glucose results between 100 mg/dL (5.56 mmol/L) and 125 mg/dL (6.9 mmol/L) indicate prediabetes. A diagnosis of impaired glucose tolerance is made if the 2-hour oral glucose tolerance test (OGTT) results are between 140 mg/dL (7.8 mmol/L) and 199 mg/dL (11.0 mmol/L).

Question 6

The nurse is teaching the patient with prediabetes ways to prevent or delay the development of type 2 diabetes. What information should be included (select all that apply)

a. Maintain a healthy weight.
b. Exercise for 60 minutes each day.
c. Have blood pressure checked regularly.
d. Assess for visual changes on monthly basis.
e. Monitor for polyuria, polyphagia, and polydipsia

Answer 6

a. Maintain a healthy weight.
e. Monitor for polyuria, polyphagia, and polydipsia

To reduce the risk of developing diabetes, the patient with prediabetes should learn to monitor for symptoms of diabetes, have blood glucose and glycosylated hemoglobin (A1C) tested regularly, maintain a healthy weight, exercise regularly, and eat a healthy diet.

Question 7

In type 1 diabetes there is an osmotic effect of glucose when insulin deficiency prevents the use of glucose for energy. What classic symptom is caused by the osmotic effect of glucose?

a. Fatigue
b. Polydipsia
c. Polyphagia
d. Recurrent infections

Answer 7

b. Polydipsia

Polydipsia is caused by fluid loss from polyuria when high glucose levels cause osmotic diuresis. Cellular starvation from lack of glucose and the use of body fat and protein for energy contribute to fatigue, weight loss, and polyphagia in type 1 diabetes.

Question 8

Which patient should the nurse plan to teach how to prevent or delay the development of diabetes?

a. An obese 50-year-old Hispanic woman
b. A child whose father has type 1 diabetes
c. A 34-year-old woman whose parents both have type 2 diabetes
d. A 12-year-old boy whose father has maturity onset diabetes of the young (MODY)

Answer 8

c. A 34-year-old woman whose parents both have type 2 diabetes

Type 2 diabetes has a strong genetic influence and offspring of parents who both have type 2 diabetes have an increased chance of developing it. In contrast, type 1 diabetes is associated with a genetic susceptibility that is related to human leukocyte antigens (HLAs). Offspring of parents who both have type 1 diabetes have a 1% to 4% chance of developing the disease. Other risk factors for type 2 diabetes include obesity; being a Native American, Hispanic, or African American; and being 55 years or older. Although 50% of people with a parent with maturity-onset diabetes of the young (MODY) will develop MODY, it is autosomal dominant and treatment depends on which genetic mutation caused it. It is not associated with obesity or hypertension and is not currently considered preventable.

Question 9

When caring for a patient with metabolic syndrome, what should the nurse give the highest priority to teaching the patient about?

a. Achieving a normal weight
b. Performing daily aerobic exercise
c. Eliminating red meat from the diet
d. Monitoring the blood glucose periodically

Answer 9

a. Achieving a normal weight

Metabolic syndrome is a cluster of abnormalities that include elevated glucose levels, abdominal obesity, elevated blood pressure, high levels of triglycerides, and low levels of high-density lipoproteins (HDLs). Overweight individuals with metabolic syndrome can prevent or delay the onset of diabetes through a program of weight loss. Exercise is also important but normal weight is most important.

Question 10

Who of the following is at the highest risk for developing type 2 diabetes?

a. A 44-year-old Native American Indian who has a body mass index (BMI) of 32.
b. A 55-year-old Asian American who has hypertension and two siblings with type 2 diabetes.
c. A child whose father has type I diabetes.
d. An 62-year-old obese white man.

Answer 10

b. A 55-year-old Asian American who has hypertension and two siblings with type 2 diabetes.

Question 11

A client screened for diabetes at a clinic has a fasting plasma glucose level of 120 mg/dL. The nurse will plan to teach the client about

a. Self-monitoring of blood glucose (accucheck at home)
b. Use of low doses of regular insulin
c. Lifestyle change to lower blood glucose
d. Effect of oral hypoglycemic medications

Answer 11

c. Lifestyle change to lower blood glucose

Question 12

The client with type I diabetes mellitus is taught to take NPH (Humulin N) at 5 pm. each day. The client should be instructed that the greatest risk of hypoglycemia will occur at about what time?

a. 11 a.m., shortly before lunch.
b. 1 p.m., shortly after lunch.
c. 6 p.m. shortly after dinner.
d. 1 a.m., while sleeping.

Answer 12

d. 1 a.m., while sleeping.

Question 13

The nurse has been teaching the client to administer a dose of 10 units of regular insulin and 28 units of NPH insulin. The statement by the client that indicates a need for additional instruction is

a. I need to rotate injection sites among my arms, legs, buttock, and abdomen each day
b. I will buy the 0.5 ml syringes because the line marking 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 13

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

The patient should leave the syringe in place for about 5 seconds after injection to be sure that all the insulin has been injected.

Question 14

Which information will the nurse include when teaching a 50-year-old client 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 14

b. Glyburide stimulates insulin production and release from the pancreas.

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 15

A client with type 1 diabetes calls the clinic with complaints of nausea, vomiting, and diarrhea. The nurse should advise the client to

a. Hold the regular dose of insulin
b. Drink cool fluids with high glucose content
c. Check the blood glucose level every 2 to 4 hours
d. Use a less strenuous form of exercise than usual until the illness resolves

Answer 15

c. Check the blood glucose level every 2 to 4 hours

Question 16

An unresponsive client 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 16

b. insert a large-bore IV catheter

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 patient’s blood glucose and would be contraindicated.

Question 17

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 17

b. Give the patient a snack of peanut butter and crackers.

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 18

To monitor for complications in a client 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
f. Monofilament testing of the foot

Answer 18

b. Blood pressure
c. Serum creatinine
d. Urine for microalbuminuria
f. Monofilament testing of the foot

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 19

Which of the following statements is the characteristic of the pathophysiology in type 1 diabetes

a. Insulin resistance in which body tissues do not respond to insulin
b. Autoimmune destruction of Beta cells
c. Compensatory overproduction of insulin
d. Genetic predisposition

Answer 19

b. Autoimmune destruction of Beta cells

Question 20

In type 1 diabetes there is an osmotic effect of glucose when insulin deficiency prevents the use of glucose for energy. Which classic symptom is caused by the osmotic effect of glucose?

a. Fatigue
b. Polydipsia
c. Polyphagia
d. Recurrent infections

Answer 20

b. Polydipsia

Question 21

Which of the following diagnostic studies is useful in determining the degree of glucose control over the past 3 months?

a. Random plasma glucose
b. Fasting plasma glucose
c. Glycosylated hemoglobin (A1C)
d. Oral glucose tolerance test (OGTT)

Answer 21

c. Glycosylated hemoglobin (A1C)

Question 22

When should Lispro insulin (Humalog) be administered?

a. Only once a day
b. 1 hour before meals
c. 30 to 45 minutes before meals
d. At mealtime or within 15 minutes of meals

Answer 22

d. At mealtime or within 15 minutes of meals

Question 23

Kussmaul respirations is one of the symptoms indicating

a. Hypoglycemia
b. Somogyi effect
c. Diabetic ketoacidosis (DKA)
d. Hyperosmolar hyperglycemic syndrome (HHS)

Answer 23

c. Diabetic ketoacidosis (DKA)

Question 24

Which of the following characteristics does not match with the macrovascular complications of diabetes

a. Damage to large and medium-size blood vessels
b. Capillary and arteriole membrane thickening specific to diabetes
c. Associated with obesity, smoking, hypertension, and unhealthy lifestyles
d. Increase the risk for cardiovascular and cerebrovascular diseases

Answer 24

b. Capillary and arteriole membrane thickening specific to diabetes

Question 25

What manifestation should the nurse expect to find from a client diagnosed with syndrome of inappropriate antidiuretic hormone?

a. Decreased body weight
b. Decreased urinary output
c. Increased plasma osmolality
d. Increased serum sodium levels

Answer 25

b. Decreased urinary output

Question 26

An 18-year-old female client, 5’4” tall, weighing 113 kg, comes to the clinic for a nonhealing wound on her lower leg, which she has had for two (2) weeks. Which disease process should the nurse suspect the client has developed?

1. Type 1 diabetes.
2. Type 2 diabetes.
3. Gestational diabetes.
4. Acanthosis nigricans.

Answer 26

2. Type 2 diabetes.
   Type 2 diabetes is a disorder usually occurring around the age of 40, but it is now being detected in children and young adults as a result of obesity and sedentary lifestyles. Nonhealing wounds are a hallmark sign of type 2 diabetes. This client weighs 248.6 pounds and is short.

Question 27

The client diagnosed with type 1 diabetes has a glycosylated hemoglobin (A1C) of 8.1%. Which interpretation should the nurse make based on this result?

1. This result is below normal levels.
2. This result is within acceptable levels.
3. This result is above recommended levels.
4. This result is dangerously high.

Answer 27

3. This result is above recommended levels.

This result parallels a serum blood level of approximately 180 to 200 mg/dL. An A1C is a blood test reflecting average blood glucose levels over a period of three (3) months; clients with elevated blood glucose levels are at risk for developing long-term complications.

(An A1C of 13% is dangerously high - it reflects a 300 mg/dL average blood glucose levels over the past 3 months.)

Question 28

The nurse administered 28 units of Humulin N, an intermediate-acting insulin, to a client diagnosed with type 1 diabetes at 1600. Which intervention should the nurse implement?

1. Ensure the client eats the bedtime snack.
2. Determine how much food the client ate at lunch.
3. Perform a glucometer reading at 0700.
4. Offer the client protein after administering insulin.

Answer 28

1. Ensure the client eats the bedtime snack.

Humulin N peaks in 6 to 8 hours, making the client at risk for hypoglycemia around midnight, which is why the client should receive a bedtime snack. This snack will prevent nighttime hypoglycemia.

Question 29

The nurse is discussing the importance of exercising with a client diagnosed with type 2 diabetes whose diabetes is well controlled with diet and exercise. Which information should the nurse include in the teaching about diabetes?

1. Eat a simple carbohydrate snack before exercising.
2. Carry peanut butter crackers when exercising.
3. Encourage the client to walk 20 minutes three (3) times a week.
4. Perform warmup and cool-down exercises.

Answer 29

4. Perform warmup and cool-down exercises.

All clients who exercise should perform warm-up and cool-down exercises to help prevent muscle strain and injury.

1. The client diagnosed with type 2 diabetes who is not taking insulin or oral agents does not need extra food before exercise.
2. The client who is at risk for hypoglycemia when exercising should carry a simple carbohydrate, but this client is not at risk for hypoglycemia.
3. Clients with diabetes controlled by diet and exercise must exercise daily at the same amount to control the glucose level.

Question 30

A patient is admitted to ICU with DKA - Which interventions should the nurse implement (select all that apply

1. Maintain adequate ventilation
2. assess fluid volume status
3. administer IV potasium
4. Check for urinary Ketones
5. monitor intake and output

Answer 30

ALL OF THE ABOVE

1. Maintain adequate ventilation
2. assess fluid volume status
3. administer IV potassium
4. Check for urinary Ketones
5. monitor intake and output

The nurse should always address the airway when a client is seriously ill. The client must be assessed for fluid volume deficit and then for fluid volume excess are fluid replacement is started. The electrolyte imbalance of primary concern is depletion of potassium. Ketones are excreted in the urine; levels are documented from negative to large amount. Ketones should be monitored frequently. The nurse must ensure the client’s fluid intake and output are equal.

Question 31

The client with HHS was admitted yesterday with blood glucose level of 780 - clients blood glucose is now 300 - which intervention should the nurse implement.

1. increase regular insulin IV drip
2. check urine for ketones
3. provide client with therapeutic diabetic meal
4. notify HCP to obtain order to decrease insulin

Answer 31

4. notify HCP to obtain order to decrease insulin

Question 32

The emergency department nurse is caring for a client diagnosed with HHNS who has a blood glucose of 680 mg/dL. Which question should the nurse ask the client to determine the cause of this acute complication?

1. When is the last time you took your insulin?
2. When did you have your last meal?
3. Have you had some type of infection lately?
4. How long have you had diabetes?

Answer 32

3. Have you had some type of infection lately?

The most common precipitating factor is infection. The manifestations may be slow to appear, with onset ranging from 24 hours to 2 weeks.
A client with type 2 diabetes usually is prescribed oral hypoglycemic medications, not insulin. the client could not eat enough food cause a 680-mg/dL blood glucose level; therefore this question does not need to be asked.

Question 33

The charge nurse is making client assignments in ICU - which client should be assigned to most experienced nurse?

1. The client with type 2 diabetes - blood glucose 348
2. The client with type 2 experiencing hypoglycemia
3. The client with DKA who has multifocal premature ventricular contractions
4. The client with HHS with plasma osmolarity of 290

Answer 33

3. The client with DKA who has multifocal premature ventricular contractions

Multifocal PVCs, which are secondary to hypokalemia and can occur in clients with DKA, are a potentially life-threatening emergency. This client needs an experienced nurse.

Question 34

The client diagnosed with type 1 diabetes received regular insulin 2 hours ago - client in complaining of being jittery and nervous - which intervention should the nurse implement? list in order of priority

1. call the lab to confirm blood glucose level
2. Administer a quick acting carbohydrate
3. Have the client eat a bologna sandwich
4. check the client’s blood glucose level at bedside
5. Determine if the client has had anything to eat

Answer 34

5. Determine if the client has had anything to eat
6. Administer a quick acting carbohydrate
7. check the client’s blood glucose level at bedside
8. call the lab to confirm blood glucose level
9. Have the client eat a bologna sandwich (complex carb and protein)

Regular insulin peaks in 2-4 hours; therefore, the nurse should suspect a hypoglycemic reaction if the client has not eaten anything. The Antidote for insulin is glucose; therefore, the nurse should give the client some type of quick-acting food source. The nurse should obtain the client’s blood glucose level as soon as possible, most hospitals require a confirmatory serum blood glucose level. Do not wait for results to give food. A source of long-acting carbohydrate and protein should be given to prevent a reoccurrence of hypoglycemia

Question 35

What are the manifestations of DKA? Select all that apply.

a. Thirst
b. Ketonuria
c. Dehydration
d. Metabolic acidosis
e. Kussmaul’s respirations
f. Sweet fruity breath

Answer 35

All of the above.

a. Thirst
b. Ketonuria
c. Dehydration
d. Metabolic acidosis
e. Kussmaul’s respirations
f. Sweet fruity breath

Question 36

Which lab indicates that the client has prediabetes?

a. A glucose tolerance of 132.
b. A glucose tolerance of 240.
c. A fasting blood glucose of 80.
d. A fasting blood glucose of 120.

Answer 36

d. A fasting blood glucose of 120.

Question 37

The nurse is teaching a community class to people with type 2 diabetes. Which explanation explains the development of type 2 diabetes?

a. The islet cells in the pancreas stop producing insulin.
b. The client eats too many foods high in sugar.
c. The pituitary gland does not produce vasopressin.
d. The cells become resistant to the circulating insulin.

Answer 37

d. The cells become resistant to the circulating insulin.

Normally insulin binds to special receptors sites on the cell and initiates a series pf reactions involved in metabolism. In type 2 diabetes, these reactions are diminished primarily as a result of obesity and aging.

Question 38

A patient taking insulin has recorded fasting glucose levels above 200 on the last five mornings upon awakening. What should the nurse advise the patient to do first?

a. Increase the evening insulin dose to prevent the dawn phenomenon.
b. Use a single-dose insulin regimen with an intermediate acting insulin.
c. Monitor the glucose level before bedtime, between 2 and 4 am, and upon arising.
d. Decrease the insulin dosage to prevent night hypoglycemia and the somogyi effect.

Answer 38

c. Monitor the glucose level before bedtime, between 2 and 4 am, and upon arising.

Question 39

The patient with type 2 diabetes is being put on Acarbose and wants to know why she is taking it. What should the nurse include in this patient’s teaching? Select all that apply.

a. Take it with the first bite of each meal.
b. It is not used in patients with heart failure.
c. Endogenous glucose production is decreased.
d. Effectiveness is measured by two-hour postprandial glucose.
e. It delays glucose absorption from the GI tract.

Answer 39

a. Take it with the first bite of each meal.
d. Effectiveness is measured by two-hour postprandial glucose.
e. It delays glucose absorption from the GI tract.

Question 40

The nurse should observe the patient for symptoms of ketoacidosis when

1. illnesses causing nausea and vomiting leading to fluid loss
2. glucose levels become become so high that osmotic diuresis promote fluid and electrolyte loss
3. an insulin deficit causes the body to metabolize large amounts of fatty acids rather than glucose for energy
4. the patient skips meals after taking insulin, leading to rapid metabolism of glucose and breakdown of fats for energy

Answer 40

3. an insulin deficit causes the body to metabolize large amounts of fatty acids rather than glucose for energy

Question 41

What describes the difference between DKA and HHS?

1. DKA requires administration of bicarbonate to correct acidosis
2. K replacement is not necessary to monitor HHS
3. HHS requires greater fluid replacement to correct the dehydration
4. Administration of glucose is withheld in HHS until the blood glucose reaches a normal level.

Answer 41

3. HHS requires greater fluid replacement to correct the dehydration

Question 42

The nurse is assessing the feet of a client with long-term type 2 diabetes. Which assessment data warrant immediate intervention by the nurse?

a. The client has crumbling toenails.
b. The client has athlete’s foot.
c. The client has a necrotic big toe.
d. The client has thickened toenails.

Answer 42

c. The client has a necrotic big toe.

A necrotic big toe indicates “dead” tissue. The client does not feel pain, does not realize the injury, and does not seek treatment. Increased blood glucose levels decrease the oxygen supply needed to heal the wound and increase the risk for developing an infection.

Question 43

The home health nurse is completing the admission assessment for a 76-year-old client diagnosed with type 2 diabetes controlled with 70/30 insulin. Which intervention should be included in the plan of care?

a. Assess the client’s ability to read small print.
b. Monitor the client’s serum PT level.
c. Teach the client how to perform a hemoglobin A1c test daily.
d. Instruct the client to check the feet weekly.

Answer 43

a. Assess the client’s ability to read small print.

Age-related visual changes and diabetic retinopathy could cause the client to have difficulty in reading and drawing up insulin dosage accurately.

Question 44

The client with type 2 diabetes controlled with biguanide oral diabetic medication is scheduled for a computed tomography (CT) scan with contrast of the abdomen to evaluate pancreatic function. Which intervention should the nurse implement?

a. Provide a high-fat diet 24 hours prior to test.
b. Hold the biguanide medication for 48 hours prior to the test.
c. Obtained an informed consent form for the test.
d. Administer pancreatic enzymes prior to the test.

Answer 44

b. Hold the biguanide medication for 48 hours prior to the test.

Biguanide medication must be held for a test with contrast medium because it increases the risk of acidosis, which leads to renal problems.

Question 45

What are the onset, peak time and durations of rapid-acting, short-acting, intermediate acting, and long-acting insulin, and major insulin examples of each type?

Answer 45

Rapid-acting:
Onset: 10-30 minutes
Peak time: 30 min-3 hours
Duration: 3-5 hours
Major examples: lispro (Humalog), aspart (NovoLog), glulisine (Apidra)

Short acting:
Onset: 30 min-1 hour
Peak time: 2-5 hours
Duration: 5-8 hours
Major examples: Regular (Humulin R, Novolin R)

Intermediate acting: 
Onset: 1.5-4 hours
Peak: 4-12 hours
Duration: 12-18 hours
Major examples: NPH (Humulin N, Novolin N)

Long acting:
Onset: 0.8-4 hours
Peak: no pronounced peak
Duration: 24+ hours
Major examples: glargine (Lantus), detemir (Levemir)

Question 46

Which type of insulin can’t be mixed with any other insulin?

Answer 46

Long-acting cannot be mixed with any others (also can’t be diluted)

Question 47

What is basal-bolus regimen?

Answer 47

Bolus is administered before meals to control postprandial glucose levels. Rapid-acting synthetic insulin analogs should be injected within 15 minutes of meal.

Basal (backround) insulin is to control levels in between meals and overnight.

Question 48

How do you teach the patient to self-administer and store insulin? How should the patient select the site for insulin injection?

Answer 48

Extra vials may be refrigerated, vials in use can be stored at room temperature for up to 4 weeks. No exposure to direct sunlight.

Vials or syringes rolled between palms before injection 10 to 20 times (warms insulin and resuspends particles)

Self-administered insulin would be delivered subcutaneously - fastest absorption in abdomen, followed by arm, thigh and buttock. Do not inject at a site to be exercised - rotates injections within 1 particular site.

Technique for drawing up mixed - inject air into NPH vial, inject air into regular vial, draw out regular, draw out NPH (clear before cloudy). Wait 5 seconds after injecting with withdraw.

(Wait 10 seconds before withdrawing with insulin pen.)

Question 49

Can you differentiate between the symptoms, mechanisms, and solutions between Somogyi effect and Dawn phenomenon?

Answer 49

Both have hyperglycemia in the morning. Check glucose levels between 2:00 and 4:00 am to differentiate.

Somogyi effect:
Bedtime insulin –> hypoglycemia –> counter-regularly mechanism (counter-regulatory hormones - epinephrine, cortisol, growth hormone, and glucagon) –> increase gluconeogenesis and glycogenolysis –> produce rebound hyperglycemia
- S/S: morning headaches, night sweats, ketonuria, nightmares
- 2-4 am: hypoglycemia
- Solutions: bedtime snack, bedtime insulin dose rejection

Dawn phenomenon:
Increased excretion of two counterregulatory hormones (growth hormone and cortisol) in early morning hours
- Affects a majority of people with diabetes, most severe when growth hormone is peaking adolescence and young adulthood
- 2-4 am: hyperglycemia
- Solutions: low carb/high protein snack at bedtime, increase insulin or adjust timing

Question 50

Biguanides

Answer 50

Example: metformin (Glucophage)

• Reduces glucose production by the liver.
• Also enhances insulin sensitivity at tissue level and improves glucose transport into cells.
• Most common
• Hold before (1-2 days) and up to 48 hours after procedures with contrast - could pose a risk of acute kidney injury

Question 51

Sulfonylureas

Answer 51

Examples: glipizide (Glucotrol), glimepiride (Amaryl), glyburide (Micronase)

• Increases insulin production by pancreas
• Hypoglycemia major side effect. Can cause weight gain.

Question 52

Meglinitides

Answer 52

Examples: repaglinide (Prandin), nateglinide (Starlix)

• Increases release of insulin from pancreatic islets
• When taken before meal (30 min) - mimics normal response to eating
• Rapidly absorbed and eliminated, less likely to cause hypoglycemia
• Should not be taken if a meal is skipped
• Can cause weight gain

Question 53

Alpha-glucosidase inhibitors

Answer 53

Examples: acarbose (Precose)

• “Starch blockers”
• Delay absorption of glucose in intestine –> decreased postprandial blood glucose
• Increases glucose uptake in muscles, decreases endogenous glucose production
• Taken with first bite of each MAIN meal
• Measured 2 hours after meal

Question 54

Thiazolidinediones

Answer 54

Examples: pioglitazone (Actos), rosiglitazone (Avandia)

• “Insulin sensitizers” - increases insulin sensitivity but does not increase insulin production
• Big risk of adverse effects - MI, stroke, heart failure, also worsen heart failure, increased risk bladder cancer (Actos)
• Weight gain

Question 55

Dipeptidyl peptidase-4 (DPP-4) inhibitors)

Answer 55

Example: sitagliptin (Januvia)

• Allows incretin hormones to fully function (which increase insulin synthesis/release from pancreas, and decrease hepatic glucose production - both things that would be desired).
• DPP-4 inhibitors allow this by blocking DPP-4 enzyme, which inhibit incretin hormones
• Results in insulin increase, decrease in glucagon secretion, and decrease in hepatic glucose production
• Lower potential for hypoglycemia
• No weight gain side effect, unlike other meds with similar effects

Question 56

The diabetic educator is teaching a class on diabetes type 1 and is discussing sick-day rules. Which interventions should the diabetes educator include in the discussion? Select all that apply.

1. Take diabetic medication even if unable to eat the client’s normal diabetic diet.
2. If unable to eat, drink liquids equal to the client’s normal caloric intake.
3. It is not necessary to notify the health-care provider if ketones are in the urine.
4. Test blood glucose levels and test urine ketones once a day and keep a record.
5. Call the health-care provider if glucose levels are higher than 180 mg/dL.

Answer 56

1. Take diabetic medication even if unable to eat the client’s normal diabetic diet.
2. If unable to eat, drink liquids equal to the client’s normal caloric intake.
3. Call the health-care provider if glucose levels are higher than 180 mg/dL.
4. The most important issue to teach clients is to take insulin even if they are unable to eat. Glucose levels are increased with stress and illness.
5. The client should drink liquids such as regular cola or orange juice, or eat regular gelatin, which provide enough glucose to prevent hypoglycemia when receiving insulin.
6. The HCP should be notified if the blood glucose level is this high. Regular insulin may need to be prescribed to keep the blood glucose level within acceptable range.

Question 57

The client received 10 units of Humulin R, a fast-acting insulin, at 0700. At 1030 the PCT tells the nurse that the client has a headache and is really acting “funny.” Which intervention should the nurse implement first?

a. Instruct the PCT to obtain the blood glucose level.
b. Have the client drink eight (8) ounces of orange juice.
c. Go the client’s room and assess the client for hypoglycemia.
d. Prepare to administer one (1) ampule of 50% dextrose intravenously.

Answer 57

c. Go the client’s room and assess the client for hypoglycemia.

Regular insulin peaks in 2 to 4 hours. Therefore, the nurse should think about the possibility the client is having a hypoglycemic reaction and should assess the client. The nurse should not delegate nursing tasks to a UAP if the client is unstable.

Question 58

The nurse is developing a care plan for the client diagnosed with type 1 diabetes. The nurse identifies the problem “high risk for hyperglycemia related to noncompliance with the medication regimen.” Which statement is an appropriate short-term goal for the client?

a. The client will have a blood glucose level between 90 and 140 mg/dL.
b. The client will demonstrate appropriate insulin injection technique.
c. The nurse will monitor the client’s blood glucose levels four (4) times a day.
d. The client will maintain normal kidney function with 30 mL/hr urine output.

Answer 58

a. The client will have a blood glucose level between 90 and 140 mg/dL.

The short-term goal must address the response part of the nursing diagnosis, which is “high risk for hyperglycemia,” and this blood glucose range is within acceptable ranges for a client who is noncompliant.

Question 59

The client diagnosed with type 2 diabetes is admitted to the intensive care unit with HHS coma. Which assessment data should the nurse expect the client to exhibit?

a. Kussmaul’s respirations
b. Diarrhea and epigastric pain
c. Dry mucous membranes
d. Ketone breath odor

Answer 59

c. Dry mucous membranes

Dry mucous membranes are a result of the hyperglycemia and occur with both HHS and DKA.

Question 60

The elderly client is admitted to the ICU diagnosed with severe HHS. Which collaborative intervention should the nurse include in the plan of care?

a. Infuse 0.9% NS intravenously.
b. Administer intermediate-acting insulin.
c. Perform blood glucometer checks daily.
d. Monitor arterial blood gas results.

Answer 60

a. Infuse 0.9% NS intravenously.

The initial fluid replacement is 0.9% normal saline (an isotonic solution) intravenously, followed by 0.45% saline. The rate depends on the client’s fluid volume status and physical health, especially of the heart.

Question 61

Which electrolyte replacement should the nurse anticipate being ordered by the health-care provider in the client diagnosed with DKA who has just been admitted to the ICU?

a. Glucose
b. Potassium
c. Calcium
d. Sodium

Answer 61

b. Potassium

The client in DKA loses potassium from increased urinary output, acidosis, catabolic state, and vomiting. Replacement is essential for preventing cardiac dysrhythmias secondary to hypokalemia.

Question 62

Which arterial blood gas results should the nurse expect in the client diagnosed with diabetic ketoacidosis?

a. pH 7.34, PaO2 99, PaCO2 48, HCO3 24
b. pH 7.38, PaO2 95, PaCO2 40, HCO3 22
c. pH 7.46, PaO2 85, PaCO2 30, HCO3 26
d. pH 7.30, PaO2 90, PaCO2 30, HCO3 18

Answer 62

d. pH 7.30, PaO2 90, PaCO2 30, HCO3 18

This ABG indicates metabolic acidosis, which is expected in a client diagnosed with diabetic ketoacidosis.

Question 63

The nurse is teaching the client diagnosed with type 2 diabetes mellitus about diet. Which diet selection indicates the client understands the teaching?

1. A submarine sandwich, potato chips, and diet cola
2. Four (4) slices of supreme thin-crust pizza and milk
3. Smoked turkey sandwich, celery sticks, and unsweetened tea
4. A roast beef sandwich, fried onion rings and a cola

Answer 63

3. Smoked turkey sandwich, celery sticks, and unsweetened tea

Turkey is a low-fat meat. A sandwich usually means normal slices of bread and the client needs at least 50% carbohydrates in each meal. Celery sticks are not counted as carbs.

Question 64

Which assessment data indicate the client diagnosed with DKA is responding to the medical treatment?

1. the client has tented skin turgor and dry mucous membranes
2. The client is alert and oriented x 3
3. The client’s ABG results are pH 7.29, PaCO2 44, HCO3 15
4. The client’s serum potassium level is 3.3 mEq/L

Answer 64

2. The client is alert and oriented x 3

The client’s level of consciousness can be altered because of dehydration and acidosis. If the client’s sensorium is intact, the client is getting better and responding to medical treatment. These ABGs indicate metabolic acidosis and the potassium level is low and indicates hypokalemia

Question 65

A client is receiving NPH insulin 20 units subcutaneously at 0700 hours daily. At 1500 hours, the nurse finds the client apparently sleep. How would the nurse know whether the client was having a hypoglycemic reaction?

1. Feel the client and bed for dampness
2. Observe the client for Kussmaul respirations
3. Smell the client’s breath for acetone odor
4. Note if the client is incontinent of urine

Answer 65

1. Feel the client and bed for dampness

When clients are sleeping, the only observable symptom of hypoglycemia is diaphoresis. Kussmaul breathing and acetone odor to breath are indicative of hyperglycemia. Incontinence is not associated with hypoglycemia and polyuria may be associated with hyperglycemia

Question 66

A client is found to be comatose and hypoglycemic with a blood glucose level of 50mg/dL. What nursing action is implemented first?

1. infuse 1000mL of D5W over a 12-hour period
2. Administer 50% glucose intravenously
3. Check the client’s urine for the presence of sugar and acetone
4. Encourage the client to drink orange juice with added sugar

Answer 66

2. Administer 50% glucose intravenously

The unconscious, hypoglycemic client needs immediate treatment with 50% intravenous glucose (highly concentrated). Administering 1000mL of D5W over 12 hours does not provide enought glucose to treat the problem. Trying to give oral fluids to an unconscious client should never be done because it increases the risk for aspiration. Urine sugar does not need to be evaluated if the serum blood glucose is available.

Question 67

What will the nurse teach the client with diabetes regarding exercise in the treatment program? Select all that apply.

1. During exercise the body will use carbohydrates for energy production, which in turn will decrease the need for insulin.
2. With an increase in activity, the body will use more carbohydrates; therefore, more insulin will be required.
3. Exercise increases the HDL and decreases the chance of stroke and heart disease.
4. The increase in activity results in an increase in the use of insulin; therefore, the client should decrease his or her carbohydrate intake.
5. Exercise will improve pancreatic circulation and stimulate the islets of Langerhans to increase the production of intrinsic insulin.

Answer 67

1. During exercise the body will use carbohydrates for energy production, which in turn will decrease the need for insulin.
2. Exercise increases the HDL and decreases the chance of stroke and heart disease.

As carbohydrates are used for energy, insulin needs decrease. Therefore during exercise, carbohydrate intake should be increased to cover the increased energy requirements. The beneficial effects of regular exercise may result in a decreased need for diabetic medications in order to read target blood glucose levels. Furthermore, it may help to reduce triglycerides, LDL cholesterol levels, increase HDLs, reduce blood pressure, and improve circulation.

Question 68

A client with a diagnosis of type 2 diabetes has been ordered a course of prednisone for severe arthritic pain. An expected change that requires close monitoring by the nurse is:

1. Increased blood glucose level
2. Increased platelet aggregation
3. Increased creatinine clearance
4. Decreased white blood cell count

Answer 68

1. Increased blood glucose level

An adverse reaction to corticosteriods is hyperglycemia. A client with type 2 diabetes must monitor blood glucose levels closely while taking steroids. Clients taking corticosteroids are at an increased risk for infection due to suppressed immune response

Question 69

It is important for the nurse to teach the client which of the following about metformin (Glucophage)?

1. It may cause constipation
2. It should be taken at night
3. It should be taken with meals
4. It may increase the effects of aspirin

Answer 69

3. It should be taken with meals

Metformin (Glucophage) is administered with meals to minimize gastrointestinal effects. These adverse effects are abdominal bloating, diarrhea, nausea, vomiting, and an unpleasant metallic taste. Metformin is contraindicated in heart failure and liver disease and in clients with compromised renal function.

Question 70

A client with diabetes receives a combination of regular and NPH insulin at 0700 hours. The nurse teaches the client to be alert for signs of hypoglycemia at:

1. 12p to 1p (1200 to 1300 hours)
2. 9a and 5p (0900 and 1700 hours)
3. 10a and 10p (1000 and 2200 hours)
4. 8a and 11a (0800 and 1100 hours)

Answer 70

2. 9a and 5p (0900 and 1700 hours)

Regular insulin (a short-acting insulin) peaks in 2 to 3 hours, and NPH (an intermediate-acting insulin) peaks in 4 to 10 hours. Hypoglycemia would most likely occur between 9am and 5pm (0900 to 1700 hours)

Question 71

Which patient with type 1 diabetes mellitus would be at the highest risk for developing hypoglycemic unawareness?

1. A 58-year-old patient with diabetic retinopathy
2. A 73-year-old patient who takes propranolol (Inderal)
3. A 19-year-old patient who is on the school track team
4. A 24-year-old patient with a hemoglobin A1C of 8.9%

Answer 71

2. A 73-year-old patient who takes propranolol (Inderal)

Hypoglycemic unawareness is a condition in which a person does not experience the warning signs and symptoms of hypoglycemia until the person becomes incoherent and combative or loses consciousness. Hypoglycemic awareness is related to autonomic neuropathy of diabetes that interferes with the secretion of counterregulatory hormones that produce these symptoms. Older patients and patients who use â-adrenergic blockers (e.g., propranolol) are at risk for hypoglycemic unawareness.

Question 72

The nurse is teaching a 60-year-old woman with type 2 diabetes mellitus how to prevent diabetic nephropathy. Which statement made by the patient indicates that teaching has been successful?

1. “Smokeless tobacco products decrease the risk of kidney damage.”
2. “I can help control my blood pressure by avoiding foods high in salt.” Correct
3. “I should have yearly dilated eye examinations by an ophthalmologist.”
4. “I will avoid hypoglycemia by keeping my blood sugar above 180 mg/dL.”

Answer 72

2. “I can help control my blood pressure by avoiding foods high in salt.”

Diabetic nephropathy is a microvascular complication associated with damage to the small blood vessels that supply the glomeruli of the kidney. Risk factors for the development of diabetic nephropathy include hypertension, genetic predisposition, smoking, and chronic hyperglycemia. Patients with diabetes are screened for nephropathy annually with a measurement of the albumin-to-creatinine ratio in urine; a serum creatinine is also needed.