EXAM 3 EVOLVE NCLEX REVIEW.
CHAPTER 64
1.1.ID: 4615471568
Which explanation best assists a client in differentiating type 1 diabetes from type 2 diabetes?
A. Most clients with type 1 diabetes are born with it.
B. People with type 1 diabetes are often obese.
C. Those with type 2 diabetes make insulin, but in inadequate amounts. Correct
D. People with type 2 diabetes do not develop typical diabetic complications.
People with type 2 diabetes make some insulin but in inadequate amounts, or they have resistance to existing insulin. Although type 1 diabetes may occur early in life, it may be caused by immune responses. Obesity is typically associated with type 2 diabetes. People with type 2 diabetes are at risk for complications, especially cardiovascular complications.
2.2.ID: 4615471528
The nurse receives report on a 52-year-old client with type 2 diabetes:
Physical AssessmentDiagnostic FindingsProvider Prescriptions
Lungs clearGlucose 179 mg/dLRegular insulin 8 units if bloodglucose 250 to 275 mg/dL andcold to touch
Right great toe mottledHemoglobin A1c 6.9%Regular insulin 10 units if glucose 275 to 300 mg/dL
Client states wears eyeglasses to read Which complication of diabetes does the nurse report to the provider?
A. Poor glucose control
B. Visual changes
C. Respiratory distress
D. Decreased peripheral perfusion Correct
A cold, mottled toe may indicate arterial occlusion secondary to arterial occlusive disease or embolization; this must be reported to avoid potential gangrene and amputation. Although one glucose reading is elevated, the hemoglobin A1c indicates successful glucose control over the past 3 months. After the age of 40, reading glasses may be needed due to difficulty in accommodating to close objects. Lungs are clear and no evidence of distress is noted.
3.3.ID: 4615471536
A client with type 1 diabetes mellitus received regular insulin at 7:00 a.m. The client should be monitored for hypoglycemia at which time?A. 7:30 a.m.
B. 11:00 a.m. Correct
C. 2:00 p.m.
D. 7:30 p.m.
Onset of regular insulin is ½ to 1 hour; peak is 2 to 4 hours. Therefore, 11:00 a.m. is the anticipated peak time for regular insulin received at 7:00 a.m. For regular insulin received at 7:00 a.m., 7:30 a.m., 2:00 p.m., and 7:30 p.m. are not the anticipated peak times.
4.4.ID: 4615471550
A client newly diagnosed with diabetes is not ready or willing to learn diabetes control during the hospital stay. Which information is the priority for the nurse to teach the client and the client’s family?
A. Causes and treatment of hyperglycemia
B. Causes and treatment of hypoglycemia Correct
C. Dietary control
D. Insulin administration
The causes and treatment of hypoglycemia must be understood by the client and family to manage the client’s diabetes effectively. The causes and treatment of hyperglycemia is a topic for secondary teaching and is not the
priority for the client with diabetes. Dietary control and insulin
administration are important, but are not the priority in this situation.
5.5.ID: 4615471562
The nurse is providing discharge teaching to a client with diabetes about injury prevention for peripheral neuropathy. Which statement by the client indicates a need for further teaching?
A. “I can break in my shoes by wearing them all day.” Correct
B. “I need to monitor my feet daily for blisters or skin breaks.”
C. “I should never go barefoot.”
D. “I should quit smoking.”
Shoes should be properly fitted and worn for a few hours a day to break them in, with frequent inspection for irritation or blistering. People with diabetes have decreased peripheral circulation, so even small injuries to the feet must be managed early. Going barefoot is contraindicated. Tobacco use further decreases peripheral circulation in a client with diabetes.
6.6.ID: 4615471564
The nurse is teaching a client with type 2 diabetes about the importance of weight control. Which comment by the client indicates a need for further teaching? A. “I should begin exercising for at least an hour a day.” Correct
B. “I should monitor my diet.”
C. “If I lose weight, I may not need to use the insulin anymore.”
D. “Weight loss can be a sign of diabetic ketoacidosis.”
For long-term maintenance of major weight loss, large amounts of exercise (7 hr/wk) or moderate or vigorous aerobic physical activity may be helpful, but the client must start slowly. Monitoring the diet is key to type 2 diabetes management. Weight loss can minimize the need for insulin and can also be a sign of diabetic ketoacidosis.
7.7.ID: 4615471570
The nurse is providing discharge teaching to a client with newly diagnosed diabetes. Which statement by the client indicates a correct understanding about the need to wear a MedicAlert bracelet?
A. “If I become hyperglycemic, it is a medical emergency.”
B. “If I become hypoglycemic, I could become unconscious.” Correct
C. “Medical personnel may need confirmation of my insurance.”
D. “I may need to be admitted to the hospital suddenly.”
Hypoglycemia is the most common cause of medical emergency in clients with diabetes. A MedicAlert bracelet is helpful if the client becomes hypoglycemic and is unable to provide self-care. Hyperglycemia is not a medical emergency unless it is acidosis; people with diabetes tolerate mild hyperglycemia routinely. Insurance information and information needed for hospital admission do not appear on a MedicAlert bracelet.
8.8.ID: 4615471530
The nurse is teaching a client about the manifestations and emergency treatment of hypoglycemia. In assessing the client’s knowledge, the nurse asks the client what he or she should do if feeling hungry and shaky. Which response by the client indicates a correct understanding of hypoglycemia management?
A. “I should drink a glass of water.”
B. “I should eat three graham crackers.” Correct
C. “I should give myself 1 mg of glucagon.”
D. “I should sit down and rest.”
Eating three graham crackers is a correct management strategy for mild hypoglycemia. Water or resting does not remedy hypoglycemia. Glucagon should be administered only in cases of severe hypoglycemia.
9.9.ID: 4615471544
A client has just been diagnosed with diabetes. Which factor is most important for the nurse to assess in the client before providing instruction about the disease and its management?
A. Current lifestyle
B. Educational and literacy level Correct
C. Sexual orientation
D. Current energy level
A large amount of information must be synthesized; typically written instructions are given. The client’s educational and literacy level is essential information. Although lifestyle should
be taken into account, it is not the priority. Sexual orientation will have no bearing on the ability of the client to provide self-
care. Although energy level will influence the ability to exercise, it is not essential.
10.10.ID: 4615471526
A client expresses fear and anxiety over the life changes associated with diabetes, stating, “I am scared I can’t do it all and I will get sick and be a burden on my family.” What is the nurse’s best response?
A. “It is overwhelming, isn’t it?”
B. “Let’s see how much you can learn today, so you are less nervous.”
C. “Let’s tackle it piece by piece. What is most
scary to you?” Correct
D. “Other people do it just fine.”
Suggesting the client tackle it piece by piece and asking what is most scary to him or her is the best response; this approach
will allow the client to have a sense of mastery with acceptance. Referring to the illness as overwhelming is supportive, but is not therapeutic or helpful to the client. Trying to see how much the client can learn in one day may actually cause the client to become more nervous; an overload of information is overwhelming. Suggesting that other people handle the illness just fine is belittling and dismisses the client’s concerns.
11.11.ID: 4615471532
A client recently admitted with new-onset type 2 diabetes will be discharged with a self-monitoring blood glucose machine. When is the best time for the nurse to explain to the client the proper use of the machine?
A. Day of discharge
B. On admission C. When the client states readiness
D. While performing the test in the hospital Correct
Teaching the client about the operation of the machine while performing the test in the hospital is the best way for the client to learn. The teaching can be reinforced before discharge. Instructing the client on the day of admission or the day of discharge would be overwhelming to the client because of all of the other activities taking place on those days. The client may never feel ready to learn this daunting task; the nurse must be more proactive.
12.12.ID: 4615471560
Which is the best referral that the nurse can suggest to a client who has been newly diagnosed with diabetes?
A. American Diabetes Association Correct
B. Centers for Disease Control and Prevention
C. Health care provider office
D. Pharmaceutical representative
The American Diabetes Association can provide national and regional support and resources to clients with diabetes and their families. The Centers for Disease Control and Prevention does not focus on diabetes. The client’s health care provider’s
office is not the best resource for diabetes information and support. A pharmaceutical representative is not an appropriate resource for diabetes information and support.
13.13.ID: 4615471524
A diabetic client has a glycosylated hemoglobin (HbA 1C) level of 9.4%. What does the nurse say to the client regarding this finding?
A. “Keep up the good work.”
B. “This is not good at all.”
C. “What are you doing differently?” Correct
D. “You need more insulin.”
Assessing the client’s regimen or changes he or she may have
made is the basis for formulating interventions to gain control of blood glucose. HbA1C levels for diabetic clients should be less than 7%; a value of 9.4% shows poor control over the past 3 months. Telling the client this is not good, although true, does not take into account problems that the client may be having with the regimen and sounds like scolding. Although it may be true that the client needs more insulin, an assessment of the client’s regimen is needed before decisions
are made about medications.
14.14.ID: 4615471540The nurse is teaching a client with diabetes about proper foot care. Which statement by the client indicates that teaching was effective?
A. “I should go barefoot in my house so that my feet are exposed to air.”
B. “I must inspect my shoes for foreign objects
before putting them on.” Correct
C. “I will soak my feet in warm water to soften
calluses before trying to remove them.”
D. “I must wear canvas shoes as much as possible to decrease pressure on my feet.”
To avoid injury or trauma to the feet, shoes should be inspected for foreign objects before they are put on. Diabetic clients should not go barefoot because foot injuries can occur.
To avoid injury or trauma, a callus should be removed by a podiatrist, not by the client. The diabetic client must wear firm
support shoes to prevent injury.
15.15.ID: 4615471548
An intensive care client with diabetic ketoacidosis (DKA) is receiving an insulin infusion. The cardiac monitor shows ventricular ectopy. Which assessment does the nurse make?
A. Urine output
B. 12-lead electrocardiogram (ECG)
C. Potassium level Correct
D. Rate of IV fluids
With insulin therapy, serum potassium levels fall rapidly as potassium shifts into the cells. Detecting and treating the underlying cause is essential. Insulin treats symptoms of diabetes by putting glucose into the cell as well as potassium;
ectopy, indicative of cardiac irritability, is not associated with changes in urine output. A 12-lead ECG can verify the ectopy, but the priority is to detect and fix the underlying cause. Increased fluids treat the symptoms of dehydration secondary
to DKA, but do not treat the cause.
16.16.ID: 4615471546
In reviewing the health care provider admission requests for a
client admitted in a hyperglycemic-hyperosmolar state, which request is inconsistent with this diagnosis?
A. 20 mEq KCl for each liter of IV fluid
B. IV regular insulin at 2 units/hr
C. IV normal saline at 100 mL/hr
D. 1 ampule NaHCO3 IV now Correct
NaHCO3 is given for the acid-base imbalance of diabetic ketoacidosis, not the hyperglycemic-hyperosmolar state, which presents with hyperglycemia and absence of ketosis/acidosis. KCl 20 mEq for each liter of IV fluid will correct hypokalemia from diuresis. IV regular insulin at 2 units/hr will correct hyperglycemia. IV normal saline at 100 mL/hr will correct dehydration.
17.17.ID: 4615471556
The nurse caring for four diabetic clients has all of these activities to perform. Which is appropriate to delegate to unlicensed assistive personnel (UAP)?
A. Perform hourly bedside blood glucose checks for a client with hyperglycemia. Correct
B. Verify the infusion rate on a continuous infusion insulin pump.
C. Monitor a client with blood glucose of 68 mg/dL for tremors and irritability.
D. Check on a client who is reporting palpitations and anxiety.
Performing bedside glucose monitoring is an activity that may
be delegated because it does not require extensive clinical judgment to perform; the nurse will follow up with the results. Intravenous therapy and medication administration are not within the scope of practice for UAP. The client with blood glucose of 68 mg/dL will need further monitoring, assessment,
and intervention not within the scope of practice for UAP. The client reporting palpitations and anxiety may have hypoglycemia, requiring further intervention; this client must be assessed by licensed nursing staff.
18.18.ID: 4615471554
The nurse has just taken change-of-shift report on a group of clients on the medical-surgical unit. Which client does the nurse assess first?
A. Client taking repaglinide (Prandin) who has nausea and back pain
B. Client taking glyburide (Diabeta) who is dizzy and sweaty Correct
C. Client taking metformin (Glucophage) who has abdominal cramps
D. Client taking pioglitazone (Actos) who has bilateral ankle swelling
The client taking glyburide (Diabeta) who is dizzy and sweaty has symptoms consistent with hypoglycemia and should be assessed first because this client displays the most serious adverse effect of antidiabetic medications. Although the client
taking repaglinide who has nausea and back pain requires assessment, the client taking glyburide takes priority. Metformin may cause abdominal cramping and diarrhea, but the client taking it does not require immediate assessment. Ankle swelling is an expected side effect of pioglitazone.19.19.ID: 4615471558
The nurse has just received change-of-shift report on the endocrine unit. Which client does the nurse see first?
A. Client with type 1 diabetes whose insulin pump is beeping “occlusion” Correct
B. Newly diagnosed client with type 1 diabetes
who is reporting thirst
C. Client with type 2 diabetes who has a blood
glucose of 150 mg/dL
D. Client with type 2 diabetes with a blood pressure of 150/90 mm Hg
Because glucose levels will increase quickly in clients who use
continuous insulin pumps, the nurse should assess this client and the insulin pump first to avoid diabetic ketoacidosis. Thirst is a symptom of hyperglycemia and, although important, is not a priority; the nurse could delegate a fingerstick blood glucose to unlicensed assistive personnel while assessing the client whose insulin pump is beeping. Although a blood glucose reading of 150 mg/dL is mildly elevated, this is not an emergency. Mild hypertension is also not an emergency.
20.20.ID: 4615471566
Which nursing action can the home health nurse delegate to a
home health aide who is making daily visits to a client with newly diagnosed type 2 diabetes?
A. Assist the client’s spouse in choosing appropriate dietary items.
B. Evaluate the client’s use of a home blood glucose monitor.
C. Inspect the extremities for evidence of poor
circulation.
D. Assist the client with washing the feet and applying moisturizing lotion. Correct
Assisting with personal hygiene is included in the role of home
health aides. Assisting with dietary choices, evaluating the effectiveness of teaching, and performing assessments are complex actions that should be implemented by licensed nurses.
21.21.ID: 4615471542
Which of these clients with diabetes does the endocrine unit charge nurse assign to an RN who has floated from the labor/delivery unit?
A. A 58-year-old with sensory neuropathy who
needs teaching about foot care
