Chapter 25: Drugs for Diabetes Nursing School Test Banks

Workman: Understanding Pharmacology

Chapter 25: Drugs for Diabetes

Test Bank

MULTIPLE CHOICE

1. How does the glucose we eat influence metabolism?
a. It combines with the glucose we make to form the proteins needed to replace those lost daily in stool.
b. It is composed of extra or empty calories that are not necessary for life and only contribute to obesity.
c. It is used inside cells to form the high energy substance adenosine triphosphate (ATP) needed to perform most cell functions.
d. It is converted to fats (lipids) which are used to protect the body from injury, insulate against heat loss, and provide the greatest number of needed calories.
ANS: C
Although both proteins and fats can make fuel to run the bodys actions, the main fuel provider is carbohydrate. We eat carbohydrates as sugars and starches. Once inside the digestive tract, the body converts most of the carbohydrates we eat into glucose (also called dextrose). Glucose is the most common simple carbohydrate and the main fuel for the human body. Inside cells, glucose is used to form ATP, which is the main chemical energy substance that drives all the bodys cellular reactions.

PTS: 0 DIF: Cognitive Level: Understanding (Comprehension)
REF: p. 442 TOP: Nursing Process Step: N/A
MSC: Client Needs Category: Physiological Integrity

2. What is the main role of insulin in glucose (carbohydrate) metabolism?
a. Conversion of complex carbohydrates into glucose
b. Movement of glucose from blood into the cells
c. Prevention of kidney excretion of glucose
d. Prevention of the formation of fat cells
ANS: B
Many body cells have membranes that do not allow glucose to move into the cells to participate in metabolism. When insulin binds to membrane insulin receptors, the membranes become more open to glucose, allowing it to enter.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)
REF: p. 442 TOP: Nursing Process Step: N/A
MSC: Client Needs Category: Physiological Integrity

3. What is the basic underlying pathology of diabetes mellitus?
a. Failure of insulin production or of insulin binding to its receptors
b. Loss of the ability for insulin to convert body fat into carbohydrates or glucose
c. Inability of pancreatic insulin to break down glycogen during periods of fasting
d. Loss of the ability of pancreatic insulin to process carbohydrates for intestinal elimination, resulting in excessively high blood glucose levels
ANS: A
The lack of insulin in diabetes, either from a lack of insulin secretion or from insulin receptor pathology, prevents insulin-sensitive cells from using glucose as a fuel source needed to generate the high-energy substance adenosine triphosphate (ATP).

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)
REF: p. 444 TOP: Nursing Process Step: N/A
MSC: Client Needs Category: Physiological Integrity

4. Why is it important to maintain normal blood glucose levels in the body?
a. High levels increase the risk for heart disease, strokes, blindness, and kidney failure.
b. High levels increase the risk for seizure disorders, arthritis, osteoporosis, and bone fractures.
c. Low levels increase the risk for peripheral neuropathy, Alzheimers disease, and premature aging.
d. Low levels increase the risk for obesity, pancreatitis, dehydration, and certain types of cancer.
ANS: A
A person with high blood glucose levels develops major changes in blood vessels that lead to organ damage, serious health problems, and early death. The long-term complications of diabetes include heart attacks, strokes, and kidney failure. In addition, diabetes is the main cause of foot and leg amputations and of new cases of blindness.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)
REF: pp. 445-446 TOP: Nursing Process Step: N/A
MSC: Client Needs Category: Physiological Integrity

5. How do diabetes type 1 and diabetes type 2 differ from each other?
a. Diabetes type 1 develops in people under 40 years old, whereas diabetes type 2 develops only in older people.
b. Diabetes type 2 develops in people under 40 years old, whereas diabetes type 1 develops only in older people.
c. Patients with type 1 diabetes are at higher risk for obesity and heart disease, whereas patients with type 2 diabetes are at higher risk for strokes.
d. Patients with type 1 diabetes produce no insulin, whereas patients with type 2 diabetes produce insulin but their insulin receptors are not very sensitive to it.
ANS: D
The main problem of type 1 diabetes is that the person can no longer make insulin. Without insulin, the patients blood glucose level becomes very high, but glucose cannot enter many cells. Patients who have type 1 diabetes must use insulin daily for the rest of their lives or receive a pancreas transplant. With type 2 diabetes, the person still has beta cells that make some insulin. In fact, some people who have type 2 diabetes have normal levels of insulin; however, the insulin receptors are not very sensitive to insulin. As a result, insulin does not bind as tightly to its receptors as it should and less glucose moves from the blood into the cells.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)
REF: p. 445 TOP: Nursing Process Step: N/A
MSC: Client Needs Category: Physiological Integrity

6. Why is insulin only given by injection and not as an oral drug?
a. Injected insulin works faster than oral drugs to lower blood glucose levels.
b. Insulin is a small protein that is destroyed by stomach acids and intestinal enzymes.
c. Insulin is a high-alert drug and could more easily be abused if it were available as an oral agent.
d. Oral insulin has a high first pass loss rate in the liver and would require very high dosages to be effective.
ANS: B
Because insulin is a small protein that is easily destroyed by stomach acids and intestinal enzymes, it cannot be used as an oral drug. Most commonly it is injected subcutaneously.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)
REF: p. 446 TOP: Nursing Process Step: N/A
MSC: Client Needs Category: Physiological Integrity

7. Which condition is the most dangerous adverse effect of insulin?
a. Hypoglycemia
b. Hyperglycemia
c. Severe hypotension
d. Development of insulin allergy
ANS: A
The main adverse effect of insulin is the lowering of blood glucose levels below normal (hypoglycemia). This response, also called insulin shock, is dangerous because brain cells are very sensitive to low blood glucose levels and the patient can become nonresponsive very quickly. If the problem is not corrected immediately, the patient can die or have irreversible brain damage.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)
REF: p. 448 TOP: Nursing Process Step: N/A
MSC: Client Needs Category: Physiological Integrity

8. A patient who has been newly diagnosed with diabetes and prescribed insulin therapy asks why more than one injection of insulin each day will be required. What is the nurses best response?
a. You need to start with multiple injections for practice until you become more proficient at self-injection.
b. A single daily dose of insulin would not match your blood insulin levels to your food intake patterns closely enough.
c. Using just one dose of insulin daily would require you to eat no more than one meal each day and you could not exercise.
d. If all your insulin were in just one injection, the dose would be too large to be absorbed predictably and you would be in danger of unexpected insulin shock.
ANS: B
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 variation in blood glucose levels. The best control of glucose levels occurs with multiple injections throughout the day.

PTS: 1 DIF: Cognitive Level: Applying (Application) or higher
TOP: Nursing Process Step: Implementation
MSC: Client Needs Category: Health Promotion and Maintenance

9. What is the most important action for the nurse to perform before administering a premeal short-acting insulin to a patient with type 1 diabetes?
a. Looking up the time the long-acting insulin was administered
b. Assessing the body area in which the last insulin dose was injected
c. Checking whether the patients meal or snack is already on the unit
d. Holding the dose if the patients blood glucose level is under 110 mg/dL
ANS: C
The most critical adverse reaction of any insulin, especially short-acting insulin, is hypoglycemia. The patient should eat a meal or snack within 15 minutes of the insulin injection. To prevent hypoglycemia, it is best not to give insulin until food is actually on the unit and available to the patient. A delay in eating could result in severe injury. The purpose of a premeal injection of short-acting insulin is to make sure the next blood glucose measurement is normal. Therefore, even if the patients blood glucose level is under 110 mg/dL, the premeal dose is still given.

PTS: 1 DIF: Cognitive Level: Applying (Application) or higher
TOP: Nursing Process Step: Implementation
MSC: Client Needs Category: Safe and Effective Care Environment

10. The nurse is teaching a patient about injection site selection and rotation, and how to self-inject insulin. Which statement made by the patient indicates that clarification is needed?
a. The abdominal site is best because it is closest to the pancreas.
b. I can reach my thigh the best, so I will use different areas of the same thigh.
c. By rotating the sites within one area, my chance of having tissue damage is less.
d. If I change injection sites from the thigh to the arm, the rate the insulin is absorbed may be different.
ANS: A
The abdominal site has the fastest rate of absorption because of the blood vessels in the area and not because of its proximity to the pancreas. It is a good site to use because most patients have sufficient subcutaneous tissue in the area and the patient can easily see and reach it.

PTS: 1 DIF: Cognitive Level: Applying (Application) or higher
TOP: Nursing Process Step: Evaluation
MSC: Client Needs Category: Health Promotion and Maintenance

11. After gently rotating a vial of isophane insulin NPH (Humulin N), the nurse notes that the drug has a cloudy appearance. What step does the nurse take before administering it to a patient?
a. Shaking the vial for 30 seconds before using it.
b. Placing the vial in warm water to clarify the drug.
c. Discarding the current vial and opening a new one.
d. Rechecking the dosage and drawing it into the syringe.
ANS: D
Isophane insulin NPH is normally cloudy and does not clarify. If no particles are present, it is ready to use after gently rotating the vial to mix the drug. Insulin vials should never be shaken because this creates bubbles that interfere with obtaining the correct dosage.

PTS: 1 DIF: Cognitive Level: Applying (Application) or higher
TOP: Nursing Process Step: Implementation
MSC: Client Needs Category: Safe and Effective Care Environment

12. Why does the nurse avoid aspirating the syringe before injecting an insulin dose?
a. There are no blood vessels in subcutaneous tissue.
b. The needle is too thin to penetrate the wall of a vein.
c. Tissue can be damaged by pulling it into the needle.
d. Aspirating blood into the syringe affects insulin activity.
ANS: C
Blood vessels in subcutaneous tissue are small and it is not necessary to check for a blood return. Pulling tissue back into the needle can cause bruising and other tissue damage.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)
REF: p. 450 TOP: Nursing Process Step: N/A
MSC: Client Needs Category: Physiological Integrity

13. The nurse is administering insulin by subcutaneous injection to a very thin patient. Which adjustment in injection technique does the nurse use to reduce the risk for complications?
a. Selecting a 30-gauge needle rather than a 28-gauge needle
b. Switching the injection site to the thigh rather than the abdomen
c. Applying pressure for at least 5 minutes after removing the needle
d. Placing the needle at a 45-degree angle rather than at a 90-degree angle
ANS: D
A very thin patient has a thinner layer of subcutaneous tissue anywhere in the body compared with a patient of normal weight. Injecting at a 90-degree angle could penetrate through the thin patients subcutaneous tissue and allow the drug to enter a muscle, which could then be absorbed too rapidly.

PTS: 1 DIF: Cognitive Level: Applying (Application) or higher
TOP: Nursing Process Step: Implementation
MSC: Client Needs Category: Physiological Integrity

14. A patient is prescribed to take insulin Glargine once per day and regular insulin four times per day. The first dose of regular insulin occurs at the same time of the day as the insulin Glargine dose. Which technique does the nurse use to administer these two drugs?
a. Drawing up and injecting the insulin Glargine first, then drawing up and injecting the dose of regular insulin.
b. Drawing up and injecting the insulin Glargine first, waiting 1 hour, then drawing up and injecting the dose of regular insulin.
c. First drawing up the dose of regular insulin, then drawing up the dose of insulin Glargine in the same syringe, followed by injecting the two insulins together.
d. First drawing up the dose of insulin Glargine, then drawing up the dose of regular insulin in the same syringe, followed by injecting the two insulins together.
ANS: A
Insulin Glargine must not be diluted or mixed with any other insulin or solution. Mixing results in an unpredictable alteration in the onset of action and time to peak action. Thus even though these two drugs are to be administered at the same time, separate injections are needed.

PTS: 1 DIF: Cognitive Level: Applying (Application) or higher
TOP: Nursing Process Step: Safe and Effective Care Environment
MSC: Client Needs Category: Physiological Integrity

15. A patient who received 22 units of regular insulin an hour ago is now pale, sweaty, and has trembling hands, but is alert and able to talk. What is the nurses best first action?
a. Prepare to administer intravenous (IV) glucose immediately.
b. Check the patients blood glucose level immediately.
c. Notify the prescriber or rapid response team immediately.
d. Give the patient a snack containing protein and a complex carbohydrate immediately.
ANS: B
The symptoms that the patient is experiencing are associated with hypoglycemia and that is the most likely problem, although other health issues can also cause these symptoms. Because the patient is alert and able to follow commands, IV administration of glucose is not necessary and calling the prescriber or rapid response team is not needed. It may be necessary to administer oral glucose but there is time to immediately check the patients blood glucose level to determine how much to give. An oral snack of protein and complex carbohydrate would not be useful for an actual hypoglycemic situation although it could prevent a later hypoglycemic episode.

PTS: 1 DIF: Cognitive Level: Applying (Application) or higher
TOP: Nursing Process Step: Evaluation MSC: Client Needs Category: Physiological Integrity

16. Which blood laboratory test result indicates to the nurse that the patient is maintaining overall good control of his or her diabetes?
a. Hemoglobin A1c is 5.2%.
b. Ketone levels are negative.
c. Fasting blood glucose level is 88 mg/dL.
d. Glucose level immediately following a meal is 150%.
ANS: A
Hemoglobin A1c levels reflect the amount of fluctuation of blood glucose levels for at least the last 60 days. The closer this number is to normal, the fewer episodes of hyperglycemia the patient will have experienced. Although a fasting blood glucose level of 88% and a negative blood ketone level are good, they only reflect the control a patient has experienced for the past 24 hours. Glucose levels immediately after a meal are the least accurate way to measure glucose control.

PTS: 1 DIF: Cognitive Level: Applying (Application) or higher
TOP: Nursing Process Step: Evaluation MSC: Client Needs Category: Physiological Integrity

17. What is the most important precaution for the nurse to teach a patient who is on insulin therapy?
a. Avoid sharing needles with family members.
b. Do not skip meals when taking insulin.
c. Always refrigerate your insulin.
d. Avoid eating carbohydrates.
ANS: B
Although sharing needles with family members greatly increases the risk for infection and for transmission of bloodborne diseases, skipping meals while taking insulin can cause severe hypoglycemia that results in brain damage or death. Most insulins do not have to be refrigerated after opening as long as they are not exposed to high temperatures or direct sunlight. The amount of carbohydrate that a patient with diabetes eats varies with activity and control of the disease. Although they may be limited, carbohydrates should not be avoided.

PTS: 1 DIF: Cognitive Level: Applying (Application) or higher
TOP: Nursing Process Step: Implementation
MSC: Client Needs Category: Health Promotion and Maintenance

18. An older patient with diabetes is visually impaired and asks if syringes can be prefilled and stored for use later. What is the nurses best response?
a. Yes, prefilled syringes can be stored for up to 3 weeks in the refrigerator in a vertical position with the needle pointing up.
b. Yes, prefilled syringes can be stored for up to 3 weeks in the refrigerator, placed in a horizontal position.
c. Insulin reacts with plastic, so prefilled syringes must be made of glass and placed in a horizontal position.
d. No, insulin cannot be stored for any length of time outside of the container.
ANS: A
Insulin is relatively stable when stored in a cool, dry place away from light. When refrigerated, prefilled syringes are stable up to 3 weeks and should be stored in the vertical position with the needle pointing up to prevent suspended insulin particles from clogging the needle.

PTS: 1 DIF: Cognitive Level: Applying (Application) or higher
TOP: Nursing Process Step: Implementation
MSC: Client Needs Category: Health Promotion and Maintenance

19. A patient who has been self-injecting insulin for 10 years now has warmth, redness, and pain at the injection site. What is the nurses best action?
a. Hold the next dose of insulin and notify the prescriber as soon as possible.
b. Teach the patient to apply ice to the area and use a different site for injection.
c. Ask how long the problem has been present and assess the patient for other symptoms of infection.
d. Document the response and reassure the patient that this is a common response that requires no action.
ANS: C
These symptoms are indicators of injection site infection. Patients with diabetes are at a greater risk for any type of infection, and infections can become severe very quickly. The nurse must determine if the area is infected or just irritated. Other indicators of infection include purulent drainage, increased firmness to the touch, and possibly fever. In either case, the area is not used for insulin injection until the infection or irritation clears. If infection is suspected, the prescriber must be notified and the patient started on antibiotic therapy as soon as possible.

PTS: 1 DIF: Cognitive Level: Applying (Application) or higher
TOP: Nursing Process Step: Assessment MSC: Client Needs Category: Physiological Integrity

20. Which problem associated with insulin therapy and diabetes is intensified for a patient who also is prescribed warfarin (Coumadin) or a beta adrenergic blocker?
a. Hypoglycemia
b. Nausea and vomiting
c. Coronary artery disease
d. Risk for excessive bleeding
ANS: A
Some drugs intensify the effects of insulin and greatly increase the risk for hypoglycemia. In addition, drugs such as beta adrenergic blockers also reduce the patients perception of hypoglycemia, further increasing hypoglycemic risk. Insulin does not affect the action of warfarin, so it does not increase the risk for bleeding. Although diabetes increases the risk for coronary artery disease, insulin therapy helps reduce that risk. Insulin is not associated with nausea or vomiting as side effects.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)
REF: p. 453 TOP: Nursing Process Step: N/A
MSC: Client Needs Category: Physiological Integrity

21. Why are oral antidiabetic drugs not effective in the management of type 1 diabetes?
a. These drugs are too powerful to give to children.
b. Patients with type 1 diabetes do not produce insulin.
c. The oral drugs are less predictable in lowering blood glucose levels.
d. Patients with type 1 diabetes are more likely to have allergies to these drugs.
ANS: B
Oral antidiabetic drugs are not insulin. Most just help the patient use his or her naturally-produced insulin more efficiently, although some drugs also prevent glucose from entering the blood too quickly.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)
REF: pp. 446, 453 TOP: Nursing Process Step: N/A
MSC: Client Needs Category: Physiological Integrity

22. How does acarbose (Precose) prevent blood glucose levels from rising too high?
a. It limits the intestinal enzyme that converts complex carbohydrates into glucose.
b. It blocks the absorption of carbohydrates and glucose in the intestines.
c. It enhances the binding of insulin to its membrane receptors.
d. It releases more insulin from pancreatic beta cells.
ANS: A
Acarbose is an alpha-glucosidase inhibitor. Drugs from this class work by slowing the digestion of dietary starches and other carbohydrates by inhibiting an enzyme that breaks them down into glucose. The result of this action is that blood glucose does not rise as far or as fast after a meal.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)
REF: p. 454 TOP: Nursing Process Step: N/A
MSC: Client Needs Category: Physiological Integrity

23. A patient with type 2 diabetes and heart failure who is prescribed metformin extended release (Glucophage XR) once daily now has muscle aches, drowsiness, low blood pressure, and a slow irregular heartbeat. What is the nurses best action?
a. Assess the patients blood glucose level and prepare to administer intravenous (IV) glucose.
b. Assess the patients blood glucose level and prepare to administer insulin.
c. Hold the dose and notify the prescriber immediately.
d. Administer the drug at bedtime to prevent falls.
ANS: C
The muscle aches, drowsiness, low blood pressure, and a slow irregular heartbeat are symptoms of lactic acidosis, an adverse reaction to metformin. The drug should be stopped and the prescriber notified so that steps can be taken to reduce the acidosis.

PTS: 1 DIF: Cognitive Level: Applying (Application) or higher
TOP: Nursing Process Step: Evaluation
MSC: Client Needs Category: Safe and Effective Care Environment

24. A patient newly diagnosed with type 2 diabetes who is prescribed rosiglitazone (Avandia) has all the following health problems. For which problem does the nurse check with the prescriber to make certain rosiglitazone is an appropriate drug choice?
a. Severe asthma for the last 3 years
b. Myocardial infarction 1 year ago
c. Uncontrolled hypertension
d. Glaucoma
ANS: B
Rosiglitazone carries a black box warning because it can cause heart failure in some patients. Patients most at risk are those who have had a previous myocardial infarction. Although heart failure can worsen asthma, it is not worsened by rosiglitazone, nor does the drug cause hypertension or glaucoma.

PTS: 1 DIF: Cognitive Level: Applying (Application) or higher
TOP: Nursing Process Step: Evaluation MSC: Client Needs Category: Physiological Integrity

25. Which blood laboratory test result is most important for the nurse to check before administering the first prescribed dose of miglitol (Glyset) to a patient?
a. International normalized ratio (INR)
b. Blood urea nitrogen (BUN) level
c. White blood cell (WBC) count
d. Lactate dehydrogenase
ANS: D
Miglitol is an alpha glucosidase inhibitor. Drugs from this class can cause liver impairment. They should not be prescribed for anyone who already had a change in liver function. A common test of liver function is blood levels of lactate dehydrogenase. Normal lactate dehydrogenase levels range between 115 and 225 international units per liter.

PTS: 1 DIF: Cognitive Level: Applying (Application) or higher
TOP: Nursing Process Step: Assessment MSC: Client Needs Category: Physiological Integrity

26. What precaution does the nurse teach a patient who is prescribed to take an oral sulfonylurea agent to maintain control of blood glucose levels?
a. Change positions slowly.
b. Stop taking this drug at the first sign of an infection.
c. Avoid taking nonsteroidal anti-inflammatory drugs.
d. Do not skip a dose of the drug even if you are unable to eat.
ANS: C
Nonsteroidal anti-inflammatory drugs (NSAIDs) potentiate the hypoglycemic effects of sulfonylurea agents. Patients should avoid these drugs altogether or use them with great caution.

PTS: 1 DIF: Cognitive Level: Applying (Application) or higher
TOP: Nursing Process Step: Implementation
MSC: Client Needs Category: Health Promotion and Maintenance

27. A patient who had been taking the oral antidiabetic agents glyburide and metformin is now prescribed only Glucovance. The patient asks why only one drug is needed. What is the nurses best response?
a. Glucovance is a new oral insulin.
b. Your diabetes is better and only one drug is needed.
c. This new drug is more effective than either glyburide or metformin.
d. Glucovance contains a combination of both glyburide and metformin.
ANS: D
Glucovance is composed of glyburide and metformin in commonly used dosages to increase the convenience of antidiabetic therapy with both drugs.

PTS: 1 DIF: Cognitive Level: Applying (Application) or higher
TOP: Nursing Process Step: Implementation
MSC: Client Needs Category: Psychosocial Integrity

28. A patient with type 2 diabetes is prescribed nateglinide (Starlix). Which statement indicates to the nurse that the patient has a correct understanding of this therapy?
a. I will try not to chew or break this tablet.
b. For best results, I need to take this drug right before I eat.
c. If this drug causes nausea, I will take it just before I go to bed.
d. If I miss a meal, I will take this drug anyway at its regularly scheduled time.
ANS: B
Nateglinide causes beta cells of the pancreas to undergo depolarization and release a small amount of preformed insulin. The peak action occurs in about 20 minutes after ingestion. To have the best action and prevent hypoglycemia, patients are instructed to take the drug within 15 minutes before eating.

PTS: 1 DIF: Cognitive Level: Applying (Application) or higher
TOP: Nursing Process Step: Evaluation
MSC: Client Needs Category: Health Promotion and Maintenance

29. A patient who is prescribed glyburide (DiaBeta) asks if having a glass of wine once a week is okay. What is the nurses best response?
a. Insulin activity is dramatically reduced under the influence of alcohol, and drinking even one glass of wine will increase your insulin requirements.
b. Diabetes reduces your kidney function, so you should avoid ingesting alcohol in all forms at all times.
c. You should not drink any alcohol as it is likely to increase your sense of hunger and make you overeat.
d. One glass of wine can be ingested with a meal on occasion and cause no problems.
ANS: D
Under normal circumstances, blood glucose levels will not be affected by moderate use of alcohol when diabetes is well controlled. When using insulin, two alcoholic beverages for men and one for women can be ingested in addition to the normal meal plan. Because alcohol can induce hypoglycemia, it should be ingested with or shortly after a meal. Although alcohol can lead to or worsen liver problems and should not be taken with drugs that affect the liver, glyburide does not appear to cause liver problems

PTS: 1 DIF: Cognitive Level: Applying (Application) or higher
TOP: Nursing Process Step: Implementation
MSC: Client Needs Category: Health Promotion and Maintenance

30. A patient who has been taking metformin (Glucophage) for a year is seen in the clinic and has all of the following laboratory results. Which result does the nurse report to the prescriber immediately?
a. Blood urea nitrogen (BUN) 38 mg/dL
b. Red blood cell (RBC) count 4.1 million/mm3
c. Random blood glucose level 135 mg/dL
d. Alkaline phosphatase 40 international units per liter
ANS: A
BUN levels are one measure of kidney health. The normal range is 10 to 20 mg/dL. An elevated BUN may indicate kidney problems or dehydration. Metformin can cause kidney problems, and the risk for lactic acidosis is increased in any patient taking metformin who has impairment of kidney function. The prescriber must be aware of the situation and explore the possibility of kidney impairment further. The drug may need to be changed to a different class of antidiabetic drug.

PTS: 1 DIF: Cognitive Level: Applying (Application) or higher
TOP: Nursing Process Step: Evaluation MSC: Client Needs Category: Physiological Integrity

31. Which fasting blood glucose level indicates to the nurse that the antidiabetic drug that has been prescribed for a patient with type 2 diabetes is effective at maintaining target blood glucose levels?
a. 40 mg/dL
b. 80 mg/dL
c. 120 mg/dL
d. 160 mg/dL
ANS: B
The most common target range of fasting blood glucose levels for a patient with type 2 diabetes is 70 to 110 mg/dL. The 40-mg level represents hypoglycemia, which is not the intention of therapy and can cause neurologic problems. Levels of 120 and 160 are considered hyperglycemia.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)
REF: p. 442 TOP: Nursing Process Step: N/A
MSC: Client Needs Category: Physiological Integrity

32. Which assessment precaution is most important for the nurse to teach a patient who is prescribed pioglitazone (Actos) as his or her only antidiabetic drug?
a. Measure your blood glucose level about 1 hour after you take this drug.
b. Note whether you experience vivid dreams or nightmares.
c. Check your urine daily for a pinkish color.
d. Weigh yourself daily and keep a record.
ANS: D
Pioglitazone is a drug from the thiazolidinedione class. Drugs from this class are associated with heart failure. An early symptom of heart failure is fluid retention leading to weight gain. A weight gain of more than 3 lb in 1 week is an indication of fluid retention.

PTS: 1 DIF: Cognitive Level: Applying (Application) or higher
TOP: Nursing Process Step: Implementation
MSC: Client Needs Category: Health Promotion and Maintenance

33. Why are sulfonylurea oral antidiabetic drugs not recommended for women who are breastfeeding?
a. They increase the risk of the infant developing type 2 diabetes.
b. They can lower the infants blood glucose to dangerous levels.
c. They can cause the infant to develop an allergy to sulfa drugs.
d. They are not eliminated by the infants immature intestinal system.
ANS: B
None of the oral antidiabetic drugs should be used by breastfeeding women because they enter the breast milk and induce side effects in the infant. Those drugs that cause hypoglycemia, such as the sulfonylureas, are especially dangerous to the infant and can lead to permanent brain damage.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)
REF: p. 458 TOP: Nursing Process Step: N/A
MSC: Client Needs Category: Physiological Integrity

34. A patient who has been prescribed sitagliptin (Januvia) calls the clinic and reports swelling of the face, lips, and tongue. What is the nurses best response?
a. Do not worry, this is a common side effect of the drug and does not require any changes.
b. Take only half the drug dose and see the prescriber within the next week.
c. Apply cold compresses to the affected areas and take an aspirin.
d. Stop taking the drug and call 911.
ANS: D
The patient has symptoms of angioedema, an allergic reaction to the drug. The swelling can continue and eventually block the patients airway. This is an emergency situation and the patient needs immediate attention. Once this reaction occurs with a drug, the patient should not take the drug or any other drug from the same class again.

PTS: 1 DIF: Cognitive Level: Applying (Application) or higher
TOP: Nursing Process Step: Evaluation MSC: Client Needs Category: Physiological Integrity

35. A patient who has been prescribed exenatide (Byetta) reports a weight loss of 11 lb in the last month. What is the nurses best action?
a. Hold the next dose and contact the prescriber immediately.
b. Ask the patient to keep a daily diary of all foods eaten for the next month.
c. Reassure the patient that this is an expected effect of the drug and no action is needed.
d. Instruct the patient to skip one dose of the drug per day and increase his or her daily calories.
ANS: C
The actions of exenatide include reducing the sensation of hunger and slowing the rate that food leaves the stomach. Both these actions help the patient eat less and lose weight, a desired outcome for patients with type 2 diabetes. An 11-lb pound weight loss in 1 month is not excessive and no action needs to be taken at this time.

PTS: 1 DIF: Cognitive Level: Applying (Application) or higher
TOP: Nursing Process Step: Implementation
MSC: Client Needs Category: Psychosocial Integrity

SEQUENCING

1. A patient is to receive 15 units of NPH insulin and 20 units of regular insulin in the same syringe. In what order does the nurse perform the steps to prepare this injection?
A. Make sure the syringe is free from air bubbles.
B. Check the syringe for a volume of insulin that is 35 units.
C. Clean the rubber stoppers of each bottle with separate alcohol swabs.
D. Check to make sure the concentration and types of insulin are correct.
E. Draw up 20 units of air and inject it into the regular insulin (short-acting insulin) bottle with the bottle in its normal, upright position.
F. Draw up 15 units of air and inject it into the NPH bottle with the bottle in its normal, upright position.
G. Place the same needle with the syringe attached into the NPH bottle, invert the bottle, and withdraw 15 units of NPH insulin into the same syringe with the regular insulin.
H. Without removing the needle, turn the bottle upside down and withdraw 20 units of regular insulin, then withdraw the needle from the bottle.

ANS:
1. D
2. C
3. F
4. E
5. H
6. A
7. G
8. B
NPH insulin and regular insulin are compatible and can be given in the same syringe. NPH insulin already contains some regular insulin but regular insulin contains no NPH insulin. Insulin is a high-alert drug and the insulin types and concentrations must be carefully checked to prevent a medication error. The tops of both vials are cleaned separately to reduce contamination with microorganisms. The amount of air injected into each vial is equal to the amount of drug to be withdrawn from the vial. Always inject the air into the intermediate-acting insulin bottle first, then inject the correct air volume into the regular insulin vial. To prevent contaminating the regular insulin, it is drawn up first after air has been injected into both vials. Drawing up the regular insulin right after injecting air into the regular insulin vial reduces the number of times the vial is penetrated. Checking for air bubbles and eliminating them before drawing up the next insulin helps ensure an accurate dose. Drawing up the NPH insulin second prevents the accidental contamination of regular insulin with NPH insulin. Checking that the volume of insulin matches the volume of each insulin added together helps ensure an accurate dose.

PTS: 1 DIF: Cognitive Level: Applying (Application) or higher
TOP: Nursing Process Step: Implementation
MSC: Client Needs Category: Safe and Effective Care Environment

ESSAY

1. A patient is prescribed repaglinide (Prandin) 3 mg. The drug available is repaglinide 0.5 mg per tablet. How many tablets does the nurse administer to the patient?
_____ tablet(s)

ANS:
6 tablets
Want 3 mg, Have 0.5 mg/tablet. 3/0.5 = 6 1 tablet = 6 tablets.

PTS: 1 DIF: Cognitive Level: Applying (Application) or higher
TOP: Nursing Process Step: Implementation
MSC: Client Needs Category: Safe and Effective Care Environment

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