Title: Exam 2
Course: NUR 1210C Adult Health

Q: The nurse administers 6 units of regular insulin and 10 units NPH insulin at 7 AM. At what time does the nurse assess the client for problems related to the NPH insulin?
- 8 AM
- 4 PM
- 8 PM
- 11 PM
A: 4 PM
If right: NPH is an intermediate-acting insulin with an onset of 1.5 hours, peak of 4 to 12 hours, and duration of action of 22 hours. Checking the client at 8:00 AM would be too soon; 8:00 PM and 11:00 PM would be too late.
If wrong: NPH is an intermediate-acting insulin with an onset of 1.5 hours, peak of 4 to 12 hours, and duration of action of 22 hours. Checking the client at 8:00 AM would be too soon; 8:00 PM and 11:00 PM would be too late.

Q: A client is being treated for hyperglycemic-hyperosmolar state (HHS). Which clinical manifestation indicates to the nurse that the therapy needs to be adjusted?
- Serum potassium level has increased from 2.8 to 3.2 mEq/L.
- Blood osmolarity has decreased from 350 to 330 mOsm.
- Score on the Glasgow Coma Scale is unchanged from 3 hours ago.
- Urine has remained negative for ketone bodies for the past 3 hours.
A: Score on the Glasgow Coma Scale is unchanged from 3 hours ago.
If right: A slow but steady improvement in central nervous system (CNS) functioning is the best indicator of therapy effectiveness for HHS. Lack of improvement in level of consciousness may indicate inadequate rates of fluid replacement. The other assessment findings do not indicate adequacy of treatment.
If wrong: A slow but steady improvement in central nervous system (CNS) functioning is the best indicator of therapy effectiveness for HHS. Lack of improvement in level of consciousness may indicate inadequate rates of fluid replacement. The other assessment findings do not indicate adequacy of treatment.

Q: The nurse is teaching a client with type 2 diabetes about acute complications. Which teaching point by the nurse is most accurate?
- Ketosis is less prevalent among obese adults owing to the protective effects of fat.
- People with type 2 diabetes have normal lipid metabolism, so ketones are not made.
- Insulin produced in type 2 diabetes prevents fat catabolism but not hyperglycemia.
- Oral antidiabetic agents do not promote the breakdown of fat for fuel (lipolysis).
A: Insulin produced in type 2 diabetes prevents fat catabolism but not hyperglycemia.
If right: Ketosis occurs as a result of fat catabolism when intracellular glucose is unavailable for energy production. The client with type 1 diabetes becomes ketotic because he or she produces no insulin, and blood glucose cannot enter the cells. In type 2 diabetes, natural insulin production continues, although at a greatly reduced level. This level is not sufficient to keep blood glucose levels in the normal range but permits just enough glucose to enter cells for energy production, so that fats are not catabolized for this purpose. The other rationales are incorrect.
If wrong: Ketosis occurs as a result of fat catabolism when intracellular glucose is unavailable for energy production. The client with type 1 diabetes becomes ketotic because he or she produces no insulin, and blood glucose cannot enter the cells. In type 2 diabetes, natural insulin production continues, although at a greatly reduced level. This level is not sufficient to keep blood glucose levels in the normal range but permits just enough glucose to enter cells for energy production, so that fats are not catabolized for this purpose. The other rationales are incorrect.

Q: The nurse is teaching a client about sick day management. Which statement by the nurse is most accurate?
- “Continue your prescribed exercise regimen even if you are sick.”
- “Avoid eating or drinking to reduce vomiting and diarrhea.”
- “Do not use insulin or take your oral antidiabetic agent if you vomit.”
- “Monitor your blood glucose levels at least every 4 hours.”
A: “Monitor your blood glucose levels at least every 4 hours.”
If right: When ill, the client should monitor his or her blood glucose at least every 4 hours. The other statements are inaccurate.
If wrong: When ill, the client should monitor his or her blood glucose at least every 4 hours. The other statements are inaccurate.

Q: Which statement by a client with type 2 diabetes indicates a need for further teaching about diabetic management and follow-up care?
- “I need to have an annual appointment, even if my glucose levels are in good control.”
- “Because my diabetes is controlled with diet and exercise, I have to be seen only if I am sick.”
- “I can still develop complications, even though I do not have to take insulin at this time.”
- “If I have surgery or get very ill, I may have to receive insulin injections for a short time.”
A: “Because my diabetes is controlled with diet and exercise, I have to be seen only if I am sick.”
If right: Clients with diabetes need to be seen at least annually to monitor for long-term complications, including visual changes, microalbuminuria, and lipid analysis. The other statements are correct.
If wrong: Clients with diabetes need to be seen at least annually to monitor for long-term complications, including visual changes, microalbuminuria, and lipid analysis. The other statements are correct.

Q: A client has been taught about lifestyle changes to help manage newly diagnosed diabetes mellitus type 2. Which statement by the client indicates good understanding?
- “Weight gain may lead to type 1 diabetes and I would need insulin.”
- “I may not need to take medications if my weight is maintained.”
- “I do not have to check my blood glucose if my weight is in the proper range.”
- “My vision and foot pain may go away if I lose some weight.”
A: “I may not need to take medications if my weight is maintained.”
If right: Type 2 diabetes can be prevented or delayed by weight loss and increased physical activity. Encourage all clients to maintain weight within an appropriate range for height and body build. Once diagnosed with type 2 diabetes, blood glucose monitoring is indicated, regardless of whether the client is taking oral antidiabetic medications. Vision and neurologic changes will not go away with weight control.
If wrong: Type 2 diabetes can be prevented or delayed by weight loss and increased physical activity. Encourage all clients to maintain weight within an appropriate range for height and body build. Once diagnosed with type 2 diabetes, blood glucose monitoring is indicated, regardless of whether the client is taking oral antidiabetic medications. Vision and neurologic changes will not go away with weight control.

Q: A client was admitted with diabetic ketoacidosis (DKA). Which manifestations does the nurse monitor the client most closely for?
- Shallow slow respirations and respiratory alkalosis
- Decreased urine output and hyperkalemia
- Tachycardia and orthostatic hypotension
- Peripheral edema and dependent pulmonary crackles
A: Tachycardia and orthostatic hypotension
If right: DKA leads to dehydration, which is manifested by tachycardia and orthostatic hypotension. Usually clients have Kussmaul respirations, which are fast and deep. Increased urinary output (polyuria) is severe. Because of diuresis and dehydration, peripheral edema and crackles do not occur.
If wrong: DKA leads to dehydration, which is manifested by tachycardia and orthostatic hypotension. Usually clients have Kussmaul respirations, which are fast and deep. Increased urinary output (polyuria) is severe. Because of diuresis and dehydration, peripheral edema and crackles do not occur.

Q: The nurse has been teaching a client about a new diagnosis of diabetes mellitus. Which statement by the client indicates a good understanding of self-management?
- “After bathing each day, I will inspect my feet and rub lotion between my toes and on my heels.”
- “I can store 3 months’ worth of insulin at room temperature as long as the bottles are not open.”
- “My medical alert bracelet is important to identify me as having diabetes if I am unconscious.”
- “If I travel eastward to see my family, I should plan on using more insulin on the day I travel.”
A: “My medical alert bracelet is important to identify me as having diabetes if I am unconscious.”
If right: It is important to encourage clients with diabetes mellitus to wear a medical alert bracelet. This bracelet is helpful if the client becomes hypoglycemic and is unable to provide self-care. Lotion should not be applied between the toes. Insulin in active use can be stored at room temperature for 28 days; otherwise insulin is stored in the refrigerator. Eastbound travel will require a reduction in insulin.
If wrong: It is important to encourage clients with diabetes mellitus to wear a medical alert bracelet. This bracelet is helpful if the client becomes hypoglycemic and is unable to provide self-care. Lotion should not be applied between the toes. Insulin in active use can be stored at room temperature for 28 days; otherwise insulin is stored in the refrigerator. Eastbound travel will require a reduction in insulin.

Q: A client with a history of diabetes mellitus has new onset of microalbuminuria. Which component of the diet must the client reduce?
- Percentage of total calories derived from carbohydrates
- Percentage of total calories derived from proteins
- Percentage of total calories derived from fats
- Total caloric intake
A: Percentage of total calories derived from proteins
If right: Restriction of dietary protein to 0.8 g/kg body weight/day is recommended for clients with microalbuminuria to retard progression to renal failure. The other options would not be needed.
If wrong: Restriction of dietary protein to 0.8 g/kg body weight/day is recommended for clients with microalbuminuria to retard progression to renal failure. The other options would not be needed.

Q: A client has long-standing diabetes mellitus. Which finding alerts the nurse to decreased kidney function in this client?
- Urine specific gravity of 1.033
- Presence of glucose in the urine
- Presence of ketone bodies in the urine
- Sustained elevation in blood pressure
A: Sustained elevation in blood pressure
If right: Hypertension is both a cause of renal dysfunction and a result of renal dysfunction. Renal dysfunction often occurs in the client with diabetes. Glucose and ketones in the urine are consistent with diabetes mellitus but are not specific to renal function. Specific gravity is elevated with dehydration.
If wrong: Hypertension is both a cause of renal dysfunction and a result of renal dysfunction. Renal dysfunction often occurs in the client with diabetes. Glucose and ketones in the urine are consistent with diabetes mellitus but are not specific to renal function. Specific gravity is elevated with dehydration.

Q: A client with a 20-year history of diabetes mellitus is reviewing his medications with the nurse. The client holds up the bottle of duloxetine (Cymbalta) and states, “My cousin has depression and is on this drug. Do you think I’m depressed?” What is the nurse’s best response?
- “Many people with long-term diabetes become depressed after a while.”
- “It’s for peripheral neuropathy. Do you have burning pain in your feet or hands?”
- “This antidepressant also has anti-inflammatory properties for diabetic pain.”
- “That is possible, but most medications are used for several different things.”
A: “It’s for peripheral neuropathy. Do you have burning pain in your feet or hands?”
If right: Damage along nerves causes peripheral neuropathy and leads to burning pain along the nerves. Many drugs, including duloxetine (Cymbalta), can be used to treat peripheral neuropathy. The nurse should assess the client for this condition and then should provide an explanation of why this drug is being used. This medication, although it is used for depression, is not being used for that reason in this case. Cymbalta does not have anti-inflammatory properties. The last option does not provide the client with enough information to be useful.
If wrong: Damage along nerves causes peripheral neuropathy and leads to burning pain along the nerves. Many drugs, including duloxetine (Cymbalta), can be used to treat peripheral neuropathy. The nurse should assess the client for this condition and then should provide an explanation of why this drug is being used. This medication, although it is used for depression, is not being used for that reason in this case. Cymbalta does not have anti-inflammatory properties. The last option does not provide the client with enough information to be useful.

Q: A diabetic client has numbness and reduced sensation. Which intervention does the nurse teach this client to prevent injury?
- “Examine your feet daily using a mirror.”
- “Rotate your insulin injection sites.”
- “Wear white socks instead of colored socks.”
- “Use a bath thermometer to test the water temperature.”
A: “Use a bath thermometer to test the water temperature.”
If right: Clients with diminished sensory perception can easily experience a burn injury when bath water is too hot. Instead of checking the temperature of the water by feeling it, they should use a thermometer. Examining the feet daily does not prevent injury, although daily foot examinations are important to find problems so they can be addressed. Rotating insulin and wearing white socks also will not prevent injury.
If wrong: Clients with diminished sensory perception can easily experience a burn injury when bath water is too hot. Instead of checking the temperature of the water by feeling it, they should use a thermometer. Examining the feet daily does not prevent injury, although daily foot examinations are important to find problems so they can be addressed. Rotating insulin and wearing white socks also will not prevent injury.

Q: A client is receiving IV insulin for hyperglycemia. Which laboratory value requires immediate intervention by the nurse?
- Serum chloride level of 98 mmol/L
- Serum calcium level of 8.8 mg/dL
- Serum sodium level of 132 mmol/L
- Serum potassium level of 2.5 mmol/L
A: Serum potassium level of 2.5 mmol/L
If right: Insulin activates the sodium-potassium ATPase pump, increasing the movement of potassium from the extracellular fluid into the intracellular fluid, resulting in hypokalemia. In hyperglycemia, hypokalemia can also result from excessive urine loss of potassium. The chloride level is normal. The calcium and sodium levels are slightly low, but this would not be related to hyperglycemia and insulin administration.
If wrong: Insulin activates the sodium-potassium ATPase pump, increasing the movement of potassium from the extracellular fluid into the intracellular fluid, resulting in hypokalemia. In hyperglycemia, hypokalemia can also result from excessive urine loss of potassium. The chloride level is normal. The calcium and sodium levels are slightly low, but this would not be related to hyperglycemia and insulin administration.

Q: The nurse has given a client an injection of glucagon. Which action does the nurse take next?
- Apply pressure to the injection site.
- Position the client on his or her side.
- Have a padded tongue blade available.
- Elevate the head of the bed.
A: Position the client on his or her side.
If right: Glucagon administration often induces vomiting, increasing the client’s risk for aspiration. The other actions are not required.
If wrong: Glucagon administration often induces vomiting, increasing the client’s risk for aspiration. The other actions are not required.

Q: The home care nurse finds a client who has diabetes awake and alert, but shaky, diaphoretic, and weak. The nurse gives the client cup of orange juice. The client’s clinical manifestations have not changed 5 minutes later. Which is the nurse’s best next action?
- Give the client another cup of orange juice.
- Call the rescue squad for transportation to the hospital.
- Administer 10 units of regular insulin subcutaneously.
- Administer 1 mg glucagon intramuscularly.
A: Give the client another cup of orange juice.
If right: This client is experiencing mild hypoglycemia. For mild hypoglycemic manifestations, if the symptoms do not resolve immediately, repeat the treatment. The client does not need glucagon, transportation to the hospital, or insulin.
If wrong: This client is experiencing mild hypoglycemia. For mild hypoglycemic manifestations, if the symptoms do not resolve immediately, repeat the treatment. The client does not need glucagon, transportation to the hospital, or insulin.

Q: Which statement made by a diabetic client who has a urinary tract infection indicates that teaching was effective regarding antibiotic therapy?
- “If my temperature is normal for 3 days in a row, I can stop taking my medicine.”
- “If my temperature goes above 100° F (37.8° C), I should double the dose.”
- “Even if I feel completely well, I should take the medication until it is gone.”
- “When my urine no longer burns, I will no longer need to take the antibiotics.”
A: “Even if I feel completely well, I should take the medication until it is gone.”
If right: Antibiotic therapy is most effective when the client takes the prescribed medication for the entire course, not just when symptoms are present. The other statements are inaccurate.
If wrong: Antibiotic therapy is most effective when the client takes the prescribed medication for the entire course, not just when symptoms are present. The other statements are inaccurate.

Q: The nurse is teaching a client with diabetes about exercise. Which statement by the client indicates a need for further teaching?
- “I won’t exercise if I find ketones in my urine.”
- “If my blood glucose is over 200, I should not exercise.”
- “Exercise will help me keep my blood glucose down.”
- “My risks for heart disease can be modified with exercise.”
A: “If my blood glucose is over 200, I should not exercise.”
If right: Clients should not exercise if their blood glucose is over 250 mg/dL. The other statements are correct and show good understanding.
If wrong: Clients should not exercise if their blood glucose is over 250 mg/dL. The other statements are correct and show good understanding.

Q: Two months after a simultaneous pancreas-kidney (SPK) transplantation, a client is diagnosed as being in acute rejection. The client states, “I was doing so well with my new organs, and the thought of having to go back to living on hemodialysis and taking insulin is so depressing.” Which is the nurse’s best response?
- “You should have followed your drug regimen better.”
- “You should be glad that at least dialysis treatment is an option for you.”
- “One acute rejection episode does not mean that you will lose the new organs.”
- “Our center is high on the list for obtaining organs from the national registry.”
A: “One acute rejection episode does not mean that you will lose the new organs.”
If right: An episode of acute rejection does not automatically mean that the client will lose the transplant. Pharmacologic manipulation of host immune responses at this time can limit damage to the organ and allow the graft to be maintained. The other statements either belittle the client or downplay his or her concerns.
If wrong: An episode of acute rejection does not automatically mean that the client will lose the transplant. Pharmacologic manipulation of host immune responses at this time can limit damage to the organ and allow the graft to be maintained. The other statements either belittle the client or downplay his or her concerns.

Q: The home care nurse visits an older client with diabetes. For which nutritional problem does the nurse monitor this client?
- Obesity
- Malnutrition
- Alcoholism
- Hyperglycemia
A: Malnutrition
If right: Older adults are more at risk for developing malnutrition as a result of multiple factors. Inadequate income, poor dentition, decreased cognition, decreased motor ability, depression, and lack of understanding about which foods constitute an adequate diet all contribute to an increased risk for malnutrition in all older adult clients, including those with diabetes mellitus.
If wrong: Older adults are more at risk for developing malnutrition as a result of multiple factors. Inadequate income, poor dentition, decreased cognition, decreased motor ability, depression, and lack of understanding about which foods constitute an adequate diet all contribute to an increased risk for malnutrition in all older adult clients, including those with diabetes mellitus.

Q: The nurse is teaching a client with diabetes about self-care. Which activity does the nurse teach that can decrease insulin needs?
- Reducing intake of liquids to 2 L/day
- Eating animal organ meats high in insulin
- Limiting carbohydrate intake to 100 g/day
- Walking 1 mile each day
A: Walking 1 mile each day
If right: Moderate exercise, such as walking, helps regulate blood glucose levels on a daily basis and results in lowered insulin requirements for clients with type 1 diabetes. Restricting fluids and eating organ meats will not reduce insulin needs. People with diabetes need at least 130 grams of carbohydrates each day.
If wrong: Moderate exercise, such as walking, helps regulate blood glucose levels on a daily basis and results in lowered insulin requirements for clients with type 1 diabetes. Restricting fluids and eating organ meats will not reduce insulin needs. People with diabetes need at least 130 grams of carbohydrates each day.

Q: Three hours after surgery, the nurse notes that the breath of the client with type 1 diabetes has a “fruity” odor. Which is the nurse’s best first action?
- Document the finding in the client’s chart.
- Increase the IV fluid flow rate.
- Test the serum for ketone bodies.
- Perform pulmonary hygiene.
A: Test the serum for ketone bodies.
If right: The stress of surgery increases the action of counterregulatory hormones and suppresses the action of insulin, predisposing the client to ketoacidosis and metabolic acidosis. One manifestation of ketoacidosis is a “fruity” odor to the breath. Documentation should occur after all assessments have been completed. The other options are not needed for this problem.
If wrong: The stress of surgery increases the action of counterregulatory hormones and suppresses the action of insulin, predisposing the client to ketoacidosis and metabolic acidosis. One manifestation of ketoacidosis is a “fruity” odor to the breath. Documentation should occur after all assessments have been completed. The other options are not needed for this problem.

Q: A client with type 1 diabetes has a blood glucose level of 160 mg/dL on arrival at the operating room. Which is the nurse’s best action?
- Document the finding in the client’s chart.
- Administer a bolus of regular insulin IV.
- Call the physician to cancel the operation.
- Draw blood gases to assess the metabolic state.
A: Document the finding in the client’s chart.
If right: Clients who have type 1 diabetes and are having surgery have been found to have fewer complications, lower rates of infection, and better wound healing if blood glucose levels are maintained at between 140 and 180 mg/dL throughout the perioperative period. The nurse should document the finding and proceed with other operative care. The need for a bolus of insulin, for canceling the operation, or for drawing arterial blood gases (ABGs) is not present.
If wrong: Clients who have type 1 diabetes and are having surgery have been found to have fewer complications, lower rates of infection, and better wound healing if blood glucose levels are maintained at between 140 and 180 mg/dL throughout the perioperative period. The nurse should document the finding and proceed with other operative care. The need for a bolus of insulin, for canceling the operation, or for drawing arterial blood gases (ABGs) is not present.

Q: Which statement made by a client getting ready for discharge after pancreas transplantation indicates a need for further teaching about the prescribed drug regimen?
- “If I develop an infection, I should stop taking my corticosteroid.”
- “If I have pain over the transplant, I will call the surgeon immediately.”
- “I should avoid people who are ill or who have an infection.”
- “I should take my cyclosporine exactly the way I was taught.”
A: “If I develop an infection, I should stop taking my corticosteroid.”
If right: Immune suppressive agents should not be stopped without the consultation of the transplantation physician, even if an infection is present. Stopping immune suppressive therapy endangers the transplanted organ. The other statements are correct. Pain over the graft site may indicate rejection. Anti-rejection drugs cause immune suppression, and the client should avoid crowds and people who are ill. Changing the routine of anti-rejection medications may cause them to not work optimally.
If wrong: Immune suppressive agents should not be stopped without the consultation of the transplantation physician, even if an infection is present. Stopping immune suppressive therapy endangers the transplanted organ. The other statements are correct. Pain over the graft site may indicate rejection. Anti-rejection drugs cause immune suppression, and the client should avoid crowds and people who are ill. Changing the routine of anti-rejection medications may cause them to not work optimally.

Q: The nurse correlates which laboratory value with inadequate functioning of a transplanted pancreas?
- Total white blood cell count 5000/mm^3
- 50% decrease in urine amylase level
- Blood urea nitrogen 30 mg/dL
- Elevated bilirubin level
A: 50% decrease in urine amylase level
If right: Most pancreas transplants are anastomosed to the bladder and drain pancreatic enzymes into the urine. When the pancreas is rejected or is functioning inadequately, the level of pancreatic enzymes in the urine decreases. The other options are not indicative of inadequate pancreatic function.
If wrong: Most pancreas transplants are anastomosed to the bladder and drain pancreatic enzymes into the urine. When the pancreas is rejected or is functioning inadequately, the level of pancreatic enzymes in the urine decreases. The other options are not indicative of inadequate pancreatic function.

Q: To reduce complications of diabetes, the nurse teaches a client with normal kidney function to modify intake of which nutritional group?
- Fats
- Fiber
- Proteins
- Carbohydrates
A: Fats
If right: Diabetes causes abnormalities in fat metabolism that lead to hyperlipidemia. The high lipid levels can lead to atherosclerosis and to many pathologic consequences of vascular insufficiency. Specific fat recommendations can be made by the registered dietitian according to individual client factors, but reducing fat intake is healthy for all diabetic people. The client with renal insufficiency may need to limit protein. Fiber should be increased do 25 to 30 g/day, and intake of carbohydrates must be spread out throughout the day.
If wrong: Diabetes causes abnormalities in fat metabolism that lead to hyperlipidemia. The high lipid levels can lead to atherosclerosis and to many pathologic consequences of vascular insufficiency. Specific fat recommendations can be made by the registered dietitian according to individual client factors, but reducing fat intake is healthy for all diabetic people. The client with renal insufficiency may need to limit protein. Fiber should be increased do 25 to 30 g/day, and intake of carbohydrates must be spread out throughout the day.

Q: A client with diabetes has proliferative retinopathy, nephropathy, and peripheral neuropathy. Which statement by the client indicates a good understanding of the disease and exercise?
- “Because I have so many complications, I guess exercise is not a good idea.”
- “I have so many complications that I better exercise hard to keep from getting worse.”
- “I love to walk outside, but I probably better avoid doing that now.”
- “I should look into swimming or water aerobics to get my exercise.”
A: “I should look into swimming or water aerobics to get my exercise.”
If right: Exercise is not contraindicated for this client, although modifications based on existing pathology are necessary to prevent further injury. Swimming or water aerobics will give the client exercise without the worry of having the correct shoes or developing a foot injury. The client can walk outside if this is the exercise that he or she prefers. The client should not exercise too vigorously.
If wrong: Exercise is not contraindicated for this client, although modifications based on existing pathology are necessary to prevent further injury. Swimming or water aerobics will give the client exercise without the worry of having the correct shoes or developing a foot injury. The client can walk outside if this is the exercise that he or she prefers. The client should not exercise too vigorously.

Q: The nurse has been reviewing options for insulin therapy with several clients. For which client does the nurse choose to recommend the pen-type injector insulin delivery system?
- Older adult client who lives at home alone but has periods of confusion
- Client on an intensive regimen with frequent, small insulin doses
- Client from the low-vision clinic who has trouble seeing the syringe
- “Brittle” client who has frequent episodes of hypoglycemia
A: Client on an intensive regimen with frequent, small insulin doses
If right: The pen-type injector allows greater accuracy with small doses, especially doses lower than 5 units. It is not recommended for those who have visual or neurologic impairments. The client with frequent hypoglycemia would not derive special benefit from using the pen.
If wrong: The pen-type injector allows greater accuracy with small doses, especially doses lower than 5 units. It is not recommended for those who have visual or neurologic impairments. The client with frequent hypoglycemia would not derive special benefit from using the pen.

Q: A client is learning to inject insulin. Which action is important for the nurse to teach the client?
- “Do not use needles more than twice before discarding.”
- “Massage the site for 1 full minute after injection.”
- “Try to make the injection deep enough to enter muscle.”
- “Keep the vial you are using in the pantry or the bedroom drawer.”
A: “Keep the vial you are using in the pantry or the bedroom drawer.”
If right: Cold insulin directly from the refrigerator is the most common cause of irritation (not infection) at the insulin injection site. Insulin in active use can be stored at room temperature. However, the bathroom is not the best place to store any medication because of increased heat and humidity. Needles should be used only once. Massage will not prevent or treat irritation from cold insulin. Insulin is given by subcutaneous, not intramuscular, injection.
If wrong: Cold insulin directly from the refrigerator is the most common cause of irritation (not infection) at the insulin injection site. Insulin in active use can be stored at room temperature. However, the bathroom is not the best place to store any medication because of increased heat and humidity. Needles should be used only once. Massage will not prevent or treat irritation from cold insulin. Insulin is given by subcutaneous, not intramuscular, injection.

Q: A client has diabetic ketoacidosis and manifests Kussmaul respirations. What action by the nurse takes priority?
- Administration of oxygen by mask or nasal cannula
- Intravenous administration of 10% glucose
- Implementation of seizure precautions
- Administration of intravenous insulin
A: Administration of intravenous insulin
If right: The rapid, deep respiratory efforts of Kussmaul respiration is the body’s attempt to reduce the acids produced by using fat rather than glucose for fuel. The client who is in ketoacidosis and who does not also have a respiratory impairment does not need additional oxygen. Only the administration of insulin will reduce this type of respiration by assisting glucose to move into cells and to be used for fuel instead of fat. Giving the client glucose would be contraindicated. The client does not require Seizure Precautions.
If wrong: The rapid, deep respiratory efforts of Kussmaul respiration is the body’s attempt to reduce the acids produced by using fat rather than glucose for fuel. The client who is in ketoacidosis and who does not also have a respiratory impairment does not need additional oxygen. Only the administration of insulin will reduce this type of respiration by assisting glucose to move into cells and to be used for fuel instead of fat. Giving the client glucose would be contraindicated. The client does not require Seizure Precautions.

Q: A client with type 1 diabetes asks whether an occasional glass of wine is allowed in the diet. Which is the nurse’s best response?
- “Drinking any wine or alcohol will increase your insulin requirements.”
- “Because of poor kidney function, people diagnosed with diabetes should avoid alcohol at all times.”
- “You shouldn’t drink alcohol because it will make you hungry and overeat.”
- “One glass of wine is okay with a meal and is counted as two fat exchanges.”
A: “One glass of wine is okay with a meal and is counted as two fat exchanges.”
If right: Under normal circumstances, blood glucose levels will not be affected by moderate use of alcohol when diabetes is well controlled. Because alcohol can induce hypoglycemia, it should be ingested with or shortly after a meal. One alcoholic beverage is substituted for two fat exchanges when caloric intake is calculated. The other statements are incorrect.
If wrong: Under normal circumstances, blood glucose levels will not be affected by moderate use of alcohol when diabetes is well controlled. Because alcohol can induce hypoglycemia, it should be ingested with or shortly after a meal. One alcoholic beverage is substituted for two fat exchanges when caloric intake is calculated. The other statements are incorrect.

Q: A client in the emergency department has been diagnosed with ketoacidosis. Which manifestation does the nurse correlate with this condition?
- Increased rate and depth of respiration
- Extremity tremors followed by seizure activity
- Oral temperature of 102° F (38.9° C)
- Severe orthostatic hypotension
A: Increased rate and depth of respiration
If right: Ketoacidosis decreases the pH of the blood, stimulating the respiratory control areas of the brain to buffer the effects of increasing acidosis. The rate and depth of respiration are increased (Kussmaul respirations) in an attempt to excrete more acids by exhalation.
If wrong: Ketoacidosis decreases the pH of the blood, stimulating the respiratory control areas of the brain to buffer the effects of increasing acidosis. The rate and depth of respiration are increased (Kussmaul respirations) in an attempt to excrete more acids by exhalation.

Q: The nurse determines that which arterial blood gas values are consistent with ketoacidosis in the client with diabetes?
- pH 7.38, HCO_3^– 22 mEq/L, PCO_2 38 mm Hg, PO_2 98 mm Hg
- pH 7.28, HCO_3^– 18 mEq/L, PCO_2 28 mm Hg, PO_2 98 mm Hg
- pH 7.48, HCO_3^– 28 mEq/L, PCO_2 38 mm Hg, PO_2 98 mm Hg
- pH 7.28, HCO_3^– 22 mEq/L, PCO_2 58 mm Hg, PO_2 88 mm Hg
A: pH 7.28, HCO_3^– 18 mEq/L, PCO_2 28 mm Hg, PO_2 98 mm Hg
If right: When the lungs can no longer offset acidosis, the pH decreases to below normal. The arterial blood gases show primary metabolic acidosis with decreased bicarbonate levels and a compensatory respiratory alkalosis with decreased carbon dioxide levels.
If wrong: When the lungs can no longer offset acidosis, the pH decreases to below normal. The arterial blood gases show primary metabolic acidosis with decreased bicarbonate levels and a compensatory respiratory alkalosis with decreased carbon dioxide levels.

Q: The client with type 2 diabetes has recently been changed from the oral antidiabetic agents glyburide (Micronase) and metformin (Glucophage) to glyburide-metformin (Glucovance). The nurse includes which information in the teaching about this medication?
- “Glucovance is more effective than glyburide and metformin.”
- “Glucovance contains a combination of glyburide and metformin.”
- “Glucovance is a new oral insulin and replaces all other oral antidiabetic agents.”
- “Your diabetes is improving and you now need only one drug.”
A: “Glucovance contains a combination of glyburide and metformin.”
If right: Glucovance is composed of glyburide and metformin. It is given to enhance the convenience of antidiabetic therapy with glyburide and metformin. The other statements are not accurate.
If wrong: Glucovance is composed of glyburide and metformin. It is given to enhance the convenience of antidiabetic therapy with glyburide and metformin. The other statements are not accurate.

Q: Which statement made by a client with type 2 diabetes taking nateglinide (Starlix) indicates understanding of this therapy?
- “I’ll take this medicine with my meals.”
- “I’ll take this medicine right before I eat.”
- “I’ll take this medicine just before I go to bed.”
- “I’ll take this medicine when I wake up in the morning.”
A: “I’ll take this medicine right before I eat.”
If right: Nateglinide is an insulin secretagogue that is designed to increase meal-related insulin secretion. It should be taken just before a meal. The other options are incorrect.
If wrong: Nateglinide is an insulin secretagogue that is designed to increase meal-related insulin secretion. It should be taken just before a meal. The other options are incorrect.

Q: A client who has been taking pioglitazone (Actos) for 6 months reports to the nurse that his urine has become darker since starting the medication. Which is the nurse’s first action?
- Review results of liver enzyme studies.
- Document the report in the client’s chart.
- Instruct the client to increase water intake.
- Test a sample of urine for occult blood.
A: Review results of liver enzyme studies.
If right: Thiazolidinediones (including pioglitazone) can affect liver function; liver function should be assessed at the start of therapy and at regular intervals while the client continues to take these drugs. Dark urine is one indicator of liver impairment because bilirubin is increased in the blood and is excreted in the urine. The nurse should check the client’s most recent liver function studies. Documentation should be done after all assessments have been completed. The client does not need to be told to increase water intake, and the nurse does not need to check the urine for occult blood.
If wrong: Thiazolidinediones (including pioglitazone) can affect liver function; liver function should be assessed at the start of therapy and at regular intervals while the client continues to take these drugs. Dark urine is one indicator of liver impairment because bilirubin is increased in the blood and is excreted in the urine. The nurse should check the client’s most recent liver function studies. Documentation should be done after all assessments have been completed. The client does not need to be told to increase water intake, and the nurse does not need to check the urine for occult blood.

Q: A client with diabetes asks why more than one injection of insulin is required each day. Which is the nurse’s best response?
- “You need to start with multiple injections until you become more proficient at self-injection.”
- “A single dose of insulin each day would not match your blood insulin levels and your food intake patterns closely enough.”
- “A regimen of a single dose of insulin injected each day would require that you could eat no more than one meal each day.”
- “A single dose of insulin would be too large to be absorbed predictably, so you would be in danger of unexpected insulin shock.”
A: “A single dose of insulin each day would not match your blood insulin levels and your food intake patterns closely enough.”
If right: Even when a single injection of insulin contains a combined dose of different-acting insulins, the timing of the actions and the timing of food intake may not match well enough to prevent wide variations in blood glucose levels.
If wrong: Even when a single injection of insulin contains a combined dose of different-acting insulins, the timing of the actions and the timing of food intake may not match well enough to prevent wide variations in blood glucose levels.

Q: Which client is at greatest risk for undiagnosed diabetes mellitus?
- Young, muscular white man
- Young African-American man
- Middle-aged Asian woman
- Middle-aged American Indian woman
A: Middle-aged American Indian woman
If right: Diabetes is a particular problem among African Americans, Hispanics, and American Indians. The incidence of diabetes increases in all races and ethnic groups with age. Being both an American Indian and middle-aged places a person at highest risk.
If wrong: Diabetes is a particular problem among African Americans, Hispanics, and American Indians. The incidence of diabetes increases in all races and ethnic groups with age. Being both an American Indian and middle-aged places a person at highest risk.

Q: The nurse is teaching a client about self-monitoring of blood glucose levels. To prevent bloodborne infection, which statement by the nurse is best?
- “Wash your hands after completing the test.”
- “Do not share your monitoring equipment.”
- “Blot excess blood from the strip.”
- “Use gloves during monitoring.”
A: “Do not share your monitoring equipment.”
If right: Small particles of blood can adhere to the monitoring device, and infection can be transported from one user to another. Hepatitis B in particular can survive in a dried state for about a week. The client should be taught to avoid sharing any equipment, including the lancet holder. The client should be taught to wash hands before testing. The client would not need to blot excess blood away from the strip or to wear gloves.
If wrong: Small particles of blood can adhere to the monitoring device, and infection can be transported from one user to another. Hepatitis B in particular can survive in a dried state for about a week. The client should be taught to avoid sharing any equipment, including the lancet holder. The client should be taught to wash hands before testing. The client would not need to blot excess blood away from the strip or to wear gloves.

Q: A client with diabetes has frequent blood glucose readings higher than 300 mg/dL. Which action does the nurse teach the client about self-care?
- Check urine ketones when blood glucose readings are high.
- Increase the insulin dose after two high glucose readings in a row.
- Change the diet to include a 10% increase in protein.
- Work out on the treadmill whenever glucose readings are high.
A: Check urine ketones when blood glucose readings are high.
If right: Urine should be tested for ketone bodies whenever the client has a blood glucose higher than 300 mg/dL; is acutely ill, under stress, pregnant, or participating in a weight reduction program; or has symptoms of ketoacidosis (nausea, vomiting, and abdominal pain). The client should not change diet and insulin dosages without input from the health care provider. The client should not exercise when blood glucose is higher than 250 mg/dL.
If wrong: Urine should be tested for ketone bodies whenever the client has a blood glucose higher than 300 mg/dL; is acutely ill, under stress, pregnant, or participating in a weight reduction program; or has symptoms of ketoacidosis (nausea, vomiting, and abdominal pain). The client should not change diet and insulin dosages without input from the health care provider. The client should not exercise when blood glucose is higher than 250 mg/dL.

Q: A client who has type 2 diabetes is prescribed glipizide (Glucotrol). Which precautions does the nurse include in the teaching plan related to this medication?
- “Change positions slowly when you get up.”
- “Avoid taking nonsteroidal anti-inflammatory drugs.”
- “If you miss a dose of this drug, you can double the next dose.”
- “Discontinue the medication if you develop an infection.”
A: “Avoid taking nonsteroidal anti-inflammatory drugs.”
If right: Nonsteroidal anti-inflammatory drugs potentiate the hypoglycemic effects of sulfonylurea agents. Glipizide is a sulfonylurea. The other statements are not applicable to glipizide.
If wrong: Nonsteroidal anti-inflammatory drugs potentiate the hypoglycemic effects of sulfonylurea agents. Glipizide is a sulfonylurea. The other statements are not applicable to glipizide.