1.

Knowing that gluconeogenesis helps to maintain blood levels, a nurse should:

1. Document weight changes because of fatty acid mobilization

2. Evaluate the patient’s sensitivity to low room temperatures because of decreased adipose
tissue insulation
3. Protect the patient from sources of infection because of decreased cellular protein deposits
4. Do all of the above

2. Clinical manifestations associated with a diagnosis of type 1 DM include all of the following
except:

1. Hypoglycemia
2. Hyponatremia
3. Ketonuria
4. Polyphagia

3. The lowest fasting plasma glucose level suggestive of a diagnosis of DM is:

1. 90mg/dl
2. 115mg/dl
3. 126mg/dl
4. 180mg/dl

4. Rotation sites for insulin injection should be separated from one another by 2.5 cm (1 inch)
and should be used only every:

1. Third day
2. Week
3. 2-3 weeks
4. 2-4 weeks

5. A clinical feature that distinguishes a hypoglycemic reaction from a ketoacidosis reaction is:
1. Blurred vision
2. Diaphoresis
3. Nausea
4. Weakness

6. Clinical nursing assessment for a patient with microangiopathy who has manifested impaired
peripheral arterial circulation includes all of the following except:

1. Integumentary inspection for the presence of brown spots on the lower extremities
2. Observation for paleness of the lower extremities
3. Observation for blanching of the feet after the legs are elevated for 60 seconds
4. Palpation for increased pulse volume in the arteries of the lower extremities

7. The nurse expects that a type 1 diabetic may receive ____ of his or her morning dose of
insulin preoperatively:

1. 10-20%
2. 25-40%
3. 50-60%
4. 85-90%

8. Albert, a 35-year-old insulin dependent diabetic, is admitted to the hospital with a diagnosis of
pneumonia. He has been febrile since admission. His daily insulin requirement is 24 units of
NPH. Every morning Albert is given NPH insulin at 0730. Meals are served at 0830, 1230, and
1830. The nurse expects that the NPH insulin will reach its maximum effect (peak) between the
hours of:

1. 1130 and 1330

2. 1330 and 1930
3. 1530 and 2130
4. 1730 and 2330
9. A bedtime snack is provided for Albert. This is based on the knowledge that intermediate-
acting insulins are effective for an approximate duration of:

1. 6-8 hours
2. 10-14 hours
3. 16-20 hours
4. 24-28 hours

10. Albert refuses his bedtime snack. This should alert the nurse to assess for:

1. Elevated serum bicarbonate and a decreased blood pH.

2. Signs of hypoglycemia earlier than expected.
3. Symptoms of hyperglycemia during the peak time of NPH insulin.
4. Sugar in the urine

11. A client is taking NPH insulin daily every morning. The nurse instructs the client that the
most likely time for a hypoglycemic reaction to occur is:

1. 2-4 hours after administration

2. 6-14 hours after administration
3. 16-18 hours after administration
4. 18-24 hours after administration

12. An external insulin pump is prescribed for a client with DM. The client asks the nurse about
the functioning of the pump. The nurse bases the response on the information that the pump:

1. Gives small continuous dose of regular insulin subcutaneously, and the client can self-
administer a bolus with an additional dosage from the pump before each meal.
2. Is timed to release programmed doses of regular or NPH insulin into the bloodstream at
specific intervals.
3. Is surgically attached to the pancreas and infuses regular insulin into the pancreas, which in
turn releases the insulin into the bloodstream.
4. Continuously infuses small amounts of NPH insulin into the bloodstream while regularly
monitoring blood glucose levels.

13. A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in the ER. Which
finding would a nurse expect to note as confirming this diagnosis?

1. Elevated blood glucose level and a low plasma bicarbonate

2. Decreased urine output
3. Increased respirations and an increase in pH
4. Comatose state

14. A client with DM demonstrates acute anxiety when first admitted for the treatment of
hyperglycemia. The most appropriate intervention to decrease the client’s anxiety would be to:

1. Administer a sedative
2. Make sure the client knows all the correct medical terms to understand what is happening.
3. Ignore the signs and symptoms of anxiety so that they will soon disappear
4. Convey empathy, trust, and respect toward the client.

15. A nurse is preparing a plan of care for a client with DM who has hyperglycemia. The priority
nursing diagnosis would be:

1. High risk for deficient fluid volume

2. Deficient knowledge: disease process and treatment
3. Imbalanced nutrition: less than body requirements
4. Disabled family coping: compromised.

16. A nurse is caring for a client admitted to the ER with DKA. In the acute phase the priority
nursing action is to prepare to:

1. Administer regular insulin intravenously

2. Administer 5% dextrose intravenously (should be NS)
3. Correct the acidosis
4. Apply an electrocardiogram monitor.
17. A nurse performs a physical assessment on a client with type 2 DM. Findings include a
fasting blood glucose of 120mg/dl, temperature of 101, pulse of 88, respirations of 22, and a bp
of 140/84. Which finding would be of most concern of the nurse?

1. Pulse
2. BP
3. Respiration
4. Temperature

18. A client with type 1 DM calls the nurse to report recurrent episodes of hypoglycemia with
exercise. Which statement by the client indicated an inadequate understanding of the peak action
of NPH insulin and exercise?

1. “The best time for me to exercise is every afternoon.”

2. “The best time for me to exercise is right after I eat.”
3. “The best time for me to exercise is after breakfast.”
4. “The best time for me to exercise is after my morning snack.”

19. A client with diabetes mellitus visits a health care clinic. The client’s diabetes previously
had been well controlled with glyburide (Diabeta), 5 mg PO daily, but recently the fasting blood
glucose has been running 180-200mg/dl. Which medication, if added to the client’s regimen,
may have contributed to the hyperglycemia?

1. Prednisone (Deltasone)
2. Atenolol (Tenormin)
3. Phenelzine (Nardil)
4. Allopurinol (Zyloprim)

20. Glucose is an important molecule in a cell because this molecule is primarily used for:

1. Extraction of energy
2. Synthesis of protein
3. Building of genetic material
4. Formation of cell membranes.

21. When a client is first admitted with hyperglycemic hyperosmolar nonketotic syndrome
(HHNS), the nurse’s priority is to provide:

1. Oxygen
2. Carbohydrates
3. Fluid replacement
4. Dietary instruction

22. The nurse is admitting a client with hypoglycemia. Identify the signs and symptoms the
nurse should expect. Select all that apply.

1. Thirst
2. Palpitations
3. Diaphoresis
4. Slurred speech
5. Hyperventilation

23. When a client is in diabetic ketoacidosis, the insulin that would be administered is:

1. Human NPH insulin

2. Human regular insulin
3. Insulin lispro injection
4. Insulin glargine injection

24. The nurse recognizes that additional teaching is necessary when the client who is learning
alternative site testing (AST) for glucose monitoring says:

1. “I need to rub my forearm vigorously until warm before testing at this site.”
2. “The fingertip is preferred for glucose monitoring if hyperglycemia is suspected.”
3. “I have to make sure that my current glucose monitor can be used at an alternate site.”
4. “Alternate site testing is unsafe if I am experiencing a rapid change in glucose levels.”
25. Which adaptations should the nurse caring for a client with diabetic ketoacidosis expect the
client to exhibit? Select all that apply:

1. Sweating
2. Low PCO2
3. Retinopathy
4. Acetone breath
5. Elevated serum bicarbonate

26. A client’s blood gases reflect diabetic acidosis. The nurse should expect:

1. Increased pH
2. Decreased PO2
3. Increased PCO2
4. Decreased HCO3

27. The nurse knows that glucagon may be given in the treatment of hypoglycemia because it:

1. Inhibits gluconeogenesis
2. Stimulates the release of insulin
3. Increases blood glucose levels
4. Provides more storage of glucose.

28. A client with type 1 DM has a fingerstick glucose level of 258mg/dl at bedtime. An order for
sliding scale insulin exists. The nurse should:

1. Call the physician

2. Encourage the intake of fluids
3. Administer the insulin as ordered
4. Give the client ½ c. of orange juice

29. The physician orders 36 units of NPH and 12 units of regular insulin. The nurse plans to
administer these drugs in 1 syringe. Identify the steps in this procedure by listing them in priority
order. (1, 3, 2, 4)
1. Inject air equal to NPH dose into NPH vial
2. Invert regular insulin bottle and withdraw regular insulin dose
3. Inject air equal to regular dose into regular dose
4. Invert NPH vial and withdraw NPH dose.

30. The insulin that has the most rapid onset of action would be:

1. Lente
2. Lispro
3. Ultralente
4. Humulin N

31. A client with DM states, “I cannot eat big meals; I prefer to snack throughout the day.” The
nurse should carefully explain that the:

1. Regulated food intake is basic to control

2. Salt and sugar restriction is the main concern
3. Small, frequent meals are better for digestion
4. Large meals can contribute to a weight problem

32. A client with DM has an above-knee amputation because of severe peripheral vascular
disease, Two days following surgery, when preparing the client for dinner; it is the nurse’s
primary responsibility to:

1. Check the client’s serum glucose level

2. Assist the client out of bed to the chair
3. Place the client in a high-Fowlers position
4. Ensure that the client’s residual limb is elevated.

33. Which of the following nursing interventions should be taken for a client who complains of
nausea and vomits one hour after taking his glyburide (DiaBeta)?

1. Give glyburide again

2. Give subcutaneous insulin and monitor blood glucose
3. Monitor blood glucose closely, and look for signs of hypoglycemia.
4. Monitor blood glucose, and assess for signs of hyperglycemia.

34. Which of the following chronic complications is associated with diabetes?

1. Dizziness, dyspnea on exertion, and coronary artery disease.

2. Retinopathy, neuropathy, and coronary artery disease
3. Leg ulcers, cerebral ischemic events, and pulmonary infarcts
4. Fatigue, nausea, vomiting, muscle weakness, and cardiac arrhythmia’s

35. Rotating injection sites when administering insulin prevents which of the following
complications?

1. Insulin edema
2. Insulin lipodystrophy
3. Insulin resistance
4. Systemic allergic reactions

36. Which of the following methods of insulin administration would be used in the initial
treatment of hyperglycemia in a client with diabetic ketoacidosis?

1. Subcutaneous
2. Intramuscular
3. IV bolus only
4. IV bolus, followed by continuous infusion.

37. Insulin forces which of the following electrolytes out of the plasma and into the cells?

1. Calcium
2. Magnesium
3. Phosphorus
4. Potassium

38. Which of the following causes of HHNS is most common?

1. Insulin overdose
2. Removal of the adrenal gland
3. Undiagnosed, untreated hyperpituitarism
4. Undiagnosed, untreated diabetes mellitus

39. A client is in DKA, secondary to infection. As the condition progresses, which of the
following symptoms might the nurse see?

1. Kussmaul’s respirations and a fruity odor on the breath

2. Shallow respirations and severe abdominal pain
3. Decreased respirations and increased urine output.
4. Cheyne-stokes respirations and foul-smelling urine

40. Clients with type 1 diabetes may require which of the following changes to their daily routine
during periods of infection?

1. No changes
2. Less insulin
3. More insulin
4. Oral antidiabetic agents

Answers and Rationale

1. Answer: 4. Do all of the above

2. Answer: 1. Hypoglycemia

3. Answer: 3. 126mg/dl

4. Answer: 3. 2-3 weeks

5. Answer: 2. Diaphoresis

6. Answer: 4. Palpation for increased pulse volume in the arteries of the lower extremities
7. Answer: 3. 50-60%

8. Answer: 2. 1330 and 1930

9. Answer: 3. 16-20 hours

10. Answer: 2. Signs of hypoglycemia earlier than expected.

11. Answer: 2. 6-14 hours after administration

NPH is intermediate acting insulin. The onset of action is 1-2 hours, it peaks in 6-14 hours, and
it’s duration of action is 24 hours. Hypoglycemic reactions most likely occur during peak time.

12. Answer: 1. Gives small continuous dose of regular insulin subcutaneously, and the client can
self-administer a bolus with an additional dosage from the pump before each meal.

An insulin pump provides a small continuous dose of regular insulin subcutaneously throughout
the day and night, and the client can self-administer a bolus with additional dosage from the
pump before each meal as needed. Regular insulin is used in an insulin pump. An external pump
is not attached surgically to the pancreas.

13. Answer: 1. Elevated blood glucose level and a low plasma bicarbonate

In diabetic acidosis, the arterial pH is less than 7.35. plasma bicarbonate is less than 15mEq/L,
and the blood glucose level is higher than 250mg/dl and ketones are present in the blood and
urine. The client would be experiencing polyuria, and Kussmaul’s respirations would be present.
A comatose state may occur if DKA is not treated, but coma would not confirm the diagnosis

14. Answer: 4. Convey empathy, trust, and respect toward the client.

The most appropriate intervention is to address the client’s feelings related to the anxiety.
Administering a sedative is not the most appropriate intervention. The nurse should not ignore
the client’s anxious feelings. A client will not relate to medical terms, particularly when anxiety
exists.
15. Answer: 1. High risk for deficient fluid volume

Increased blood glucose will cause the kidneys to excrete the glucose on the urine. This glucose
is accompanied by fluids and electrolytes, causing osmotic diuresis leading to dehydration. This
fluid loss must be replaced when it becomes severe. Options B, C, and D are not related
specifically to the issue of the question.

16. Answer: 1. Administer regular insulin intravenously

Lack (absolute or relative) of insulin is the primary cause of DK1. Treatment consists of insulin
administration (regular insulin), IV fluid administration (normal saline initially), and potassium
replacement, followed by correcting acidosis. Applying an electrocardiogram monitor is not a
priority action.

17. Answer: 4. Temperature

An elevated temperature may indicate infection. Infection is a leading cause of hyperglycemic

hyperosmolar nonketotic syndrome or diabetic ketoacidosis.

18. Answer: 1. “The best time for me to exercise is every afternoon.”

A hypoglycemic reaction may occur in the response to increased exercise. Clients should avoid
exercise during the peak time of insulin. NPH insulin peaks at 6-14 hours; therefore afternoon
exercise will occur during the peak of the medication. Options B, C, and D do not address peak
action times.

19. Answer: 1. Prednisone (Deltasone)

Prednisone may decrease the effect of oral hypoglycemics, insulin, diuretics, and potassium
supplements.

20. Answer: 1. Extraction of energy

Glucose catabolism is the main pathway for cellular energy production.

21. Answer: 3. Fluid replacement

As a result of osmotic pressures created by increased serum glucose, the cells become
dehydrated; the client must receive fluid and then insulin.

22. Answer: 2, 3, 4.

Palpitations, an adrenergic symptom, occur as the glucose levels fall; the sympathetic nervous
system is activated and epinephrine and norepinephrine are secreted causing this response.
Diaphoresis is a sympathetic nervous system response that occurs as epinephrine and
norepinephrine are released. Slurred speech is a neuroglycopenic symptom; as the brain receives
insufficient glucose, the activity of the CNS becomes depressed.

23. Answer: 2. Human regular insulin

Regular insulin (Humulin R) is a short-acting insulin and is administered via IV with an initial
dose of 0.3 units/kg, followed by 0.2 units/kg 1 hour later, followed by 0.2 units/kg every 2 hours
until blood glucose becomes <13.9 mmol/L (<250 mg/dL). At this point, insulin dose should be
decreased by half, to 0.1 units/kg every 2 hours, until the resolution of DKA.

24. Answer: 2. “The fingertip is preferred for glucose monitoring if hyperglycemia is suspected.”

The fingertip is preferred for glucose monitoring if hypoglycemia, not hyperglycemia, is

suspected.

25. Answer: 2, 3.

Metabolic acidosis initiates respiratory compensation in the form of Kussmaul’s respirations to

counteract the effects of ketone buildup, resulting in a lowered PCO2. A fruity odor to the breath
(acetone breath) occurs when the ketone level is elevated in ketoacidosis.

26. Answer: 4. Decreased HCO3

The bicarbonate-carbonic acid buffer system helps maintain the pH of the body fluids; in
metabolic acidosis, there is a decrease in bicarbonate because of an increase of metabolic acids.
27. Answer: 3. Increases blood glucose levels

Glucagon, an insulin antagonist produced by the alpha cells in the islets of Langerhans, leads to
the conversion of glycogen to glucose in the liver.

28. Answer: 3. Administer the insulin as ordered

A value of 258mg/dl is above the expected range of 70-105 mg/dl; the nurse should administer
the insulin as ordered.

29. Answer: 1, 3, 2, 4.

30. Answer: 2. Lispro

Lispro has an immediate onset, a peak of 30-90 minutes, and duration of 2-4 hours.

31. Answer: 1. Regulated food intake is basic to control

An understanding of the diet is imperative for compliance. A balance of carbohydrates, proteins,

and fats usually apportioned over three main meals and two between meals snacks needs to be
tailored to the client’s specific needs, with due regard for activity, diet, and therapy.

32. Answer: 1. Check the client’s serum glucose level

Because the client has diabetes, it is essential that the blood glucose level be determined before
meals to evaluate the success of control of diabetes and the possible need for insulin coverage.

33. Answer: 3. Monitor blood glucose closely, and look for signs of hypoglycemia.

When a client who has taken an oral antidiabetic agent vomits, the nurse would monitor glucose
and assess him frequently for signs of hypoglycemia. Most of the medication has probably been
absorbed. Therefore, repeating the dose would further lower glucose levels later in the day.
Giving insulin would also lower the glucose levels, causing hypoglycemic. The client wouldn’t
have hyperglycemia if the glyburide was absorbed.
34. Answer: 2. Retinopathy, neuropathy, and coronary artery disease

These are all chronic complications of diabetes. Dizziness, dyspnea on exertion, and coronary
artery disease are symptoms of aortic valve stenosis. Fatigue, nausea, vomiting, muscle
weakness, and cardiac arrhythmias are symptoms of hyperparathyroidism. Leg ulcers, cerebral
ischemic events, and pulmonary infarcts are complications of sickle cell anemia.

35. Answer: 2. Insulin lipodystrophy

Insulin lipodystrophy produces fatty masses at the injection sites, causing unpredictable
absorption of insulin injected into these sites.

36. Answer: 4. IV bolus, followed by continuous infusion.

An IV bolus of insulin is given initially to control the hyperglycemia; followed by a continuous

infusion, titrated to control blood glucose. After the client is stabilized, subcutaneous insulin is
given. Insulin is never given intramuscularly.

37. Answer: 4. Potassium

Insulin forces potassium out of the plasma, back into the cells, causing hypokalemia. Potassium
is needed to help transport glucose and insulin into the cells. Calcium, magnesium, and
phosphorus aren’t affected by insulin.

38. Answer: 4. Undiagnosed, untreated diabetes mellitus

Undiagnosed, untreated DM is one of the most common causes of HHNS.

39. Answer: 1. Kussmaul’s respirations and a fruity odor on the breath

Coma and severe acidosis are ushered in with Kussmaul’s respirations (very deep but not labored
respirations) and a fruity odor on the breath (academia).

40. Answer: 3. More insulin

During periods of infection or illness, diabetics may need even more insulin to compensate for
increased blood glucose levels.