Diabetes Mellitus

The nurse is teaching a client with diabetes mellitus how to mix regular insulin and NPH insulin in the same syringe. Which action, if performed by the client indicates the need for further teaching?

• Withdraws the NPH insulin first.

• Withdraws the regular insulin first.

• Injects air into NPH insulin vial first.

• Injects an amount of air equal to the desired dose of insulin into each vial.

Answer explanation

When preparing a mixture of short-acting insulin, with another insulin preparation, the short-acting insulin is drawn into the syringe first. This sequence will avoid contaminating the vial of short-acting insulin with insulin of another type. Options 2, 3, and 4 identify correct actions for preparing NPH and short-acting insulin.

The home care nurse visits a client recently diagnosed with diabetes mellitus who is taking Humulin NPH insulin daily. The client asks the nurse how to store the unopened vials of insulin. The nurse should tell the client to take which action?

• Freeze the insulin.

• Refrigerate the insulin.

• Store the insulin in a dark, dry place.

• Keep the insulin at room temperature.

Answer explanation

Insulin in unopened vials should be stored under refrigeration until needed. Vials should not be frozen. When stored unopened under refrigeration, insulin can be used up to the expiration date on the vial. Options 1, 3, and 4 are incorrect.

The nurse is providing discharge teaching for a client newly diagnosed with type 2 diabetes mellitus who has been prescribed metformin. Which client statement indicates the need for further teaching?

• "It is okay if I skip meals once in a while."

• "I need to let my doctor know if I get unusually tired."

• "I need to constantly watch for signs of low blood sugar."

• "I will be sure to not drink alcohol excessively while on this medication."

Answer explanation

Metformin is classified as a biguanide and is the most commonly used medication for type 2 diabetes mellitus initially. It is also often used as a preventive medication for those at high risk to developing diabetes mellitus. When used alone, metformin lowers the blood glucose after meal intake as well as fasting blood glucose levels. Metformin does not stimulate insulin release and therefore poses little risk for hypoglycemia. For this reason, metformin is well suited for clients who skip meals. Unusual somnolence as well as hyperventilation, myalgia, and malaise are early signs of lactic acidosis, a toxic effect associated with metformin. If any of these signs or symptoms occur, the client should inform the primary health care provider immediately. While it is the best to avoid consumption of alcohol, it is not always realistic or feasible for clients to quit drinking altogether; for this reason, clients should be informed that excessive alcohol intake can cause an adverse reaction with metformin.

The primary health care provider (PHCP) prescribes exenatide for a client with type 1 diabetes mellitus who takes insulin. The nurse should plan to take which most appropriate intervention?

• Withhold the medication and call the PHCP, questioning the prescription for the client.

• Teach the client about the signs and symptoms of hypoglycemia and hyperglycemia.

• Monitor the client for gastrointestinal side effects after administering the medication.

• Withdraw the insulin from the prefilled pen into an insulin syringe to prepare for administration.

Answer explanation

Exenatide is an incretin memetic used for type 2 diabetes mellitus only. It is not recommended for clients taking insulin. Hence the nurse should withhold the medication and question the PCHP regarding this prescription. Although option 2 and 3 are correct statement about the medication, in this situation the medication should not be administered. The medication is packaged in prefilled pens ready for injection without the need for drawing it up into another syringe.

A client with diabetes mellitus is taking Humulin NPH insulin and regular insulin every morning. The nurse should provide which instructions to the client? Select all that apply.

• Hypoglycemia may be experienced before dinnertime.

• The insulin dose should be decreased if illness ocurrs.

• The insulin should be administered at room temperature.

• The insulin vial needs to be shaken vigorously to break up the precipitates.

• The NPH insulin should be drawn into the syringe first, then the regular insulin.

Answer explanation

Humulin NPH in an intermediate-acting insulin. The onset of action is 60 to 120 minutes. It peaks in 4 to 12 hours, and its duration of action is 18 to 24 hours. Regular insulin is a shor-acting insulin. Depending on the type, the onset of action is 30 to 60 minutes, it peaks in 2 to 4 hours, and its duration is 5 to 8 hours. Hypoglycemic reactions most likely occur during peak time. Insulin should be at room temperature when administered. Clients may need their insulin dosages increased during times of illness. Insulin vials should never be shaken vigorously. Regular insulin is always drawn up before NPH.

A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in the emergency department. Which findings support this diagnosis? Select all that apply.

• Increase in pH

• Comatose state

• Deep, rapid breathing

• Decreased urine output

• Elevated blood glucose level

Answer explanation

Because of the profound deficiency of insulin associated with DKA, glucose cannot be used for energy and the body breaks down fat as a secondary source of energy. Ketones, which are acid by-products of fat metabolism, build up, and the client experiences a metabolic ketoacidosis. High serum glucose contributes to an osmotic diuresis and the client becomes severely dehydrated. If untreated, the client will become comatose due to severe dehydration, acidosis, and electrolyte imbalance. Kussmaul's respirations, the deep rapid breathing associated with DKA, is a compensatory mechanism by the body. The body attempts to correct the acidotic state by blowing off carbon dioxide (CO₂), which is an acid. In the absence of insulin, the client will experience severe hyperglycemia. Option 1 is incorrect, because in acidosis the pH would be low. Option 4 is incorrect because a high serum glucose will result in an osmotic diuresis and the client will experience polyuria.

The nurse teaches a client with diabetes mellitus about differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that a form of glucose should be taken if which symptoms develop? Select all that apply.

• Polyuria and Fruity breath odor

• Shakiness

• Palpitations

• Blurred vision

• Lightheadedness

Answer explanation

Shakiness, palpitations, and lightheadedness are signs/symptoms of hypoglycemia and would indicate the need for food or glucose. Polyuria, blurred vision, and a fruity breath odor are manifestations of hyperglycemia.

The nurse provides instructions to a client newly diagnosed with type 1 diabetes mellitus. The nurse recognizes accurate understanding of measures to prevent diabetic ketoacidosis when the client makes which statement?

• "I will stop taking my insulin if I'm too sick to eat."

• "I will decrease my insulin dose during times of illness."

• "I will adjust my insulin dose according to the level of glucose in my urine."

• "I will notify my primary health care provider (PHCP) if my blood glucose level is higher than 250 mmol/L."

Answer explanation

During illness, the client with type 1 diabetes mellitus is at increased risk of diabetic ketoacidosis, due to hyperglycemia associated with the stress response and due to a typically decreased caloric intake. As part of sick day management, the client with diabetes should monitor blood glucose levels and should notify the PHCP if the level is higher than 250 mg/dL (13.9 mmol/L). Insulin should never be stopped. In fact, insulin may need to be increased during times of illness. Doses should not be adjusted without the PHCP's advice and are usually adjusted on the basis of blood glucose levels, not urinary glucose readings.

The nurse is monitoring a client newly diagnosed with diabetes mellitus for signs of complications. Which sign or symptom, if frequently exhibited in the client, indicates that the client is at risk for chronic complications of diabetes if the blood glucose is not adequately managed?

• Polyuria

• Diaphoresis

• Pedal edema

• Decreased respiratory rate

Answer explanation

Chronic hyperglycemia, resulting from poor glycemic control, contributes to the microvascular and macrovascular complications of diabetes mellitus. Classic symptoms of hyperglycemia include polydipsia, polyuria, and polyphagia. Diaphoresis may occur in hypoglycemia. Hypoglycemia is an acute complication of diabetes mellitus; however, it does not predispose a client to the chronic complications of diabetes mellitus. Therefore, option 2 can be eliminated because this finding is characteristic of hypoglycemia. Options 3 and 4 are not associated with diabetes mellitus.

The nurse is preparing a plan of care for a client with diabetes mellitus who has hyperglycemia. The nurse places priority on which client problem?

• Lack of knowledge

• Inadequate fluid volume

• Compromised family coping

• Inadequate consumption of nutrients

Answer explanation

An increased blood glucose level will cause the kidneys to excrete the glucose in the urine. This glucose is accompanied by fluids and electrolytes, causing an osmotic diuresis leading to dehydration. This fluid loss must be replaced when it becomes severe. Options 1, 3, and 4 are not related specifically to the information in the question.