PRACTICE QUESTIONS ANSWERS AND RATIONALES

Transcription

1 PRACTICE QUESTIONS ANSWERS AND RATIONALES 150 A Client with Type 1 Diabetes Humulin N is an intermediate-acting insulin that peaks 6 8 hours after administration; therefore, the client would experience signs of hypoglycemia around The nurse needs to ensure the client eats the nighttime (HS) snack to help prevent nighttime hypoglycemia. 3. A serum blood glucose level would have to be done with a venipuncture and the blood sample must be taken to the laboratory. If the client needed the blood glucose checked, it should be done with a glucometer at the bedside. 4. The supper tray would not help prevent a hypoglycemic reaction because the Humulin N is an intermediate-acting insulin that peaks in 6 8 hours The insulin pen injector resembles a fountain pen. It contains a disposable needle and insulin-filled cartridge. When the client operates the insulin pen, the correct dose is obtained by turning the dial to the number of insulin units needed. 2. The insulin pen injector does not require drawing up insulin in a syringe. 3. The insulin pen injector can be used in any subcutaneous site that traditional insulin can be injected. 4. Most clients state that there is less injection pain associated with the insulin pen than with the traditional insulin syringe Headache, nervousness, sweating, tremors, and rapid pulse are signs of a hypoglycemic reaction and should be treated with a simple-acting carbohydrate, such as orange juice, sugar-containing drinks, and hard candy. This statement indicates the client understands the teaching. 2. If a client cannot drink or eat a simple carbohydrate for hypoglycemia, then the client should receive a glucagon injection to treat the hypoglycemic reaction. This indicates the client understands the teaching. 3. Even with insulin therapy the client should adhere to the American Diabetic Association diet, which recommends carbohydrate counting. This statement indicates the client needs more teaching. 4. Monitoring and documenting the blood glucose level is encouraged to determine the effectiveness of the treatment regimen. This indicates the client understands the client teaching Regular insulin peaks in 2 4 hours; therefore, the breakfast meal would prevent the client from developing hypoglycemia. 2. Lunch would cover a 0700 dose of Humulin N, an intermediate-acting insulin. 3. Supper would cover a 1600 dose of Humulin R, a short-acting insulin. 4. The HS (nighttime) snack would cover a 1600 dose of Humulin N, an intermediateacting insulin One amp of 50% glucose would be used to treat a severe hypoglycemic reaction, and this client does not have signs or symptoms that indicate hypoglycemia. In fact, the client has signs and symptoms of hyperglycemia. 2. The client s signs and symptoms indicate the client is experiencing diabetic ketoacidosis (DKA), which is treated with intravenous regular insulin. 3. Humulin N is an intermediate-acting insulin, which is not used to treat hyperglycemia. 4. An IV of D5W would cause the client to have further signs and symptoms of diabetic ketoacidosis (DKA); therefore, the nurse should not administer the IV A portable insulin pump is a batteryoperated device that uses rapid-acting insulin Lispro, Humalog, or NovoLog. It delivers both basal insulin infusion (continuous release of a small amount of insulin) and bolus doses with meals. This provides fewer hypoglycemic reactions and better blood glucose levels. 2. The pumps do provide a memory of boluses, but that is not the nurse s best response to explain why a client should get an external portable insulin pump. 3. External portable insulin pumps are only used to deliver rapid-acting insulin subcutaneously. Intermediate- and long-acting insulins are not used with an external portable insulin pump because of unpredictable control of blood glucose. 4. The insulin pump is not recommended as the initial way to administer insulin because the success of the insulin pump depends on the client s knowledge and compliance. Initially most clients start injecting insulin with a syringe and then graduate to the pumps.

2 CHAPTER 6 ENDOCRINE SYSTEM Because the client is in the hospital the client must have a hospital identification band; a MedicAlert bracelet would be needed when the client is not in the hospital. 2. Humalog is not regular insulin; it is fastacting insulin. It is not administered according to the regular insulin sliding scale. The peak time for Humalog is 30 minutes to 1 hour; regular insulin peaks in 2 4 hours. 3. A client with Type 1 diabetes will experience diabetic ketoacidosis; a client with Type 2 diabetes will experience hyperosmolar, hyperglycemic, nonketotic coma. 4. Humalog peaks in 30 minutes to 1 hour; therefore, the client needs to eat when or shortly after the medication is administered to prevent hypoglycemia. MEDICATION MEMORY JOGGER: Remember that the different types of insulin peak at different times, and the nurse must be knowledgeable about the peak times to ensure that the client does not experience hypoglycemia. Only the insulin product Lantus has no peak time The fasting blood glucose level is obtained after the client is NPO for 8 hours; this blood result does not indicate adherence to the treatment regimen. 2. If the client has no ketones in the urine, it indicates that the body is not breaking down fat for energy, but it does not indicate adherence to the treatment regimen. 3. A glycosylated hemoglobin (A1C) gives the average of the blood glucose level over the last 3 months and indicates adherence to the medical treatment regimen. A glycosylated hemoglobin level of 5.8% is close to normal and indicates that the client is adhering to the treatment regimen. The following table shows blood glucose levels and corresponding glycosylated hemoglobin results: Blood Glucose Glycosylated Hemo- Level globin Result % Normal 6% 7% 8% 9% 10% 11% 12% 4. A glucometer reading of 120 mg/dl indicates a normal blood glucose level, but it is a one-time reading and does not indicate adherence to the medical treatment regimen This statement indicates the client understands the medication teaching. Keeping the insulin in the refrigerator will maintain the insulin s strength and potency. Once the insulin vial is opened it may be kept at room temperature for 1 month. 2. Insulin vials should not be placed in direct sunlight or in a high-temperature area, such as the trunk of a car, because it will lose its strength. 3. Insulin should not be kept in the freezer because freezing will cause the insulin to break down and lose its effectiveness. 4. Prefilled syringes should be stored in the refrigerator and should be used within 1 2 weeks, not 1 2 days The pancreas does not secrete glucose. It secretes insulin, which is the key that opens the door to allow glucose to enter the body cells. Glucose enters the body through the gastrointestinal system. 2. This statement explains the pharmacokinetics of insulin and how the body metabolizes and excretes urine. Pharmacokinetics is the process of drug movement to achieve drug interaction. 3. Insulin does not maintain colloidal osmotic pressure. Albumin, a product of protein, maintains colloidal osmotic pressure. 4. This is the statement that explains the pharmacodynamics, which is the drug s mechanism of action or way that insulin is utilized by the body. Over time, elevated glucose levels in the bloodstream can cause long-term complications, including nephropathy, retinopathy, and neuropathy. Insulin lowers blood glucose by promoting the use of glucose in body cells. A Client with Type 2 Diabetes The client with Type 2 diabetes must adhere to the prescribed diet to help keep the blood glucose level within the normal range. Delaying or missing a meal can cause hypoglycemia. This statement would not warrant intervention by the nurse. 2. The client should check blood glucose levels to determine if the medication is effective; therefore, this statement would not warrant intervention by the nurse.

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4 152 PHARMACOLOGY SUCCESS 3. Sulfonylureas and biguanides may cause an Antabuse-like reaction when taken with alcohol, causing the client to become nauseated and vomit. Advise the client to abstain from alcohol and to avoid liquid over-the-counter (OTC) medications that may contain alcohol. Alcohol also increases the half-life of the medication and can cause a hypoglycemic reaction. 4. The client with Type 2 diabetes does not need to walk daily to keep the glucose level within normal limits; walking three times a week will help control stress and help decrease weight if the client is overweight A thiazolidinedione, pioglitazone (Actos) or rosiglitazone (Avandia), not a biguanide like metformin, is prescribed to decrease insulin resistance. 2. An alpha-glucosidase inhibitor, acarbose (Precose) or miglitol (Glyset), is administered to allow carbohydrates to pass slowly through the intestine. Glucophage does not do this. 3. The scientific rationale for administering metformin (Glucophage) is that it diminishes the increase in serum glucose following a meal and blunts the degree of postprandial hyperglycemia by preventing gluconeogenesis. 4. A meglitinide, repaglinide (Prandin), sulfonylurea, or nateglinide (Starlix) is prescribed to stimulate the beta cells to release more insulin into the bloodstream The oral hypoglycemic medication should be administered with food to decrease gastric upset. 2. The client receiving oral hypoglycemic medications can experience hypoglycemic reactions, as can clients receiving insulin. 3. These are signs or symptoms of hypoglycemia, and the client should be able to treat this without notifying the health-care provider. 4. Ketones are a byproduct of the breakdown of fats, which usually does not occur in clients with Type 2 diabetes because the client has enough insulin to prevent breakdown of fats but not enough to keep the blood glucose level within an acceptable level An elastic skin turgor is expected and normal, but it does not indicate that the antidiabetic medication is effective. 2. Urine ketones should be negative because there should not be a breakdown of fat in clients with Type 2 diabetes, but this does not indicate the effectiveness of the medication. 3. The serum blood glucose level should be within normal limits, which is mg/dl. A level of 118 mg/dl is close to normal; therefore, the medication can be considered effective. 4. A self-monitoring blood glucose level of 170 mg/dl is above a normal glucose level; this indicates the medication is not effective. MEDICATION MEMORY JOGGER: The nurse determines the effectiveness of a medication by assessing for the symptoms, or lack thereof, for which the medication was prescribed During illness, the client with Type 2 diabetes may need insulin to help keep glucose levels under control, but this is a threatening type of statement and is not the nurse s best response. 2. Insulin may need to be prescribed in times of stress, surgery, or serious infection; therefore, the nurse should explain this to the client and not refer the client to the HCP. 3. This is a therapeutic response and the client needs to have factual information. Therapeutic responses are used to encourage the client to ventilate feelings. 4. Blood glucose levels elevate during times of stress, surgery, or serious infection. The client with Type 2 diabetes may need to be given insulin temporarily to help keep the blood glucose level with normal limits The client s serum blood glucose level is checked by drawing a venipuncture blood sample and sending it to the laboratory. This would take too long. The nurse must take care of the client; therefore, drawing a blood sample and awaiting results is not the first intervention. 2. The client is experiencing signs of a hypoglycemic reaction and the nurse must treat the client by administering some type of simple-acting glucose. This is the first intervention. 3. Determining when the last oral hypoglycemic medication was administered is an intervention that could be implemented, but it is not the first intervention. The nurse needs to take care of the client.

5 CHAPTER 6 ENDOCRINE SYSTEM The nurse could assess the client s vital signs, but this is not the first intervention; the nurse should take care of the client s signs and symptoms. MEDICATION MEMORY JOGGER: When answering test questions or when caring for clients at the bedside, the nurse should remember that assessing the client might not be the first action to take when the client is in distress. The nurse may need to intervene directly to help the client Changes in weight will affect the amount of medication needed to control blood glucose. The nurse should determine if the client s medication dose is too high by determining if the client has had an increase in hypoglycemic reactions. This is the nurse s first intervention. 2. A significant weight loss may require a decrease or discontinuation of oral hypoglycemic medication, but the nurse should first determine if the client has had symptoms of hypoglycemia before referring him or her to the HCP. 3. Determining if the client was deliberately losing weight or was losing without trying is significant because a 35-pound weight loss in 4 months would warrant intervention, depending on what caused the weight loss. However, this should not be the nurse s first intervention. 4. The nurse should confirm the client s weight loss with the clinic scale and the last weight in the client s chart, but it is not the clinic nurse s first intervention. MEDICATION MEMORY JOGGER: Remember that the first step in the nursing process is assessment. Words such as check, monitor, determine, ask, take, auscultate, and palpate indicate that the nurse is assessing the client. Assessment should be done before implementing an independent nursing action or notifying the health-care provider, except in certain serious or life-threatening situations The nurse should investigate any herb the client is taking because most herbs do affect a disease process or the medication being taken for the disease process. 2. The nurse should determine if ginseng affects the client s Type 2 diabetes or medications that the client is taking for the disease process. 3. This is a negative, judgmental statement. Many herbs are beneficial to the client. The nurse should always assess the client and determine if the herb is detrimental to the client s disease process or affects the client s routine medication regimen prior to making this type of statement. 4. The nurse should determine if the client is taking any medication because many oral hypoglycemics interact with herbs. Ginseng and garlic may increase the hypoglycemic effects of oral hypoglycemics. MEDICATION MEMORY JOGGER: Some herbal preparations are effective, some are not, and a few can be harmful or even deadly. If a client is taking an herbal supplement and a conventional medicine, the nurse should investigate to determine if the herbal preparation would cause harm to the client. The nurse should always be the client s advocate The students with Type 2 diabetes should not eat candy, but it is not the most important intervention for the school nurse to teach. 2. This is pertinent information, but it is not the most important information. 3. The most important information for the teachers to know is how to treat potentially life-threatening complications secondary to the medications used to treat Type 2 diabetes. The school nurse should discuss issues that keep the students safe. 4. Exercise is important in helping to control Type 2 diabetes, but empowering the teachers to be confident when handling complications secondary to medication is priority for the safety of the students Jaundiced sclera may indicate the client has hepatitis, but because the client has been prescribed oral hypoglycemic medications, their possible role in the development of the jaundice should be assessed. 2. The nurse should not jump to the conclusion that the client is an alcoholic just because the sclera is jaundiced. 3. Digoxin toxicity results in the client having a yellow haze, not the client s sclera being yellow. 4. Oral hypoglycemics are metabolized in the liver and may cause elevations in liver enzymes; the client should be instructed to report the first signs of

6 154 PHARMACOLOGY SUCCESS yellow skin, sclera, pale stools, or dark urine to the HCP. A Client with Pancreatitis Morphine can cause spasm of the pancreatic ducts and the sphincter of Oddi. Therefore, the nurse would question administering this medication. 2. Diphenhydramine is a histamine 1 blocker that blocks the release of histamine 1 that occurs during allergic reactions. The nurse would not question this medication. 3. Clients with diabetes mellitus may at times have a need for a steroid medication. The medication may elevate the client s glucose levels, and these levels should be monitored. The nurse would not question this medication. 4. Vasopressin is the hormone that is lacking in clients diagnosed with diabetes insipidus (DI) and is the treatment for DI. The nurse would not question administering this medication. MEDICATION MEMORY JOGGER: The nurse must be knowledgeable about accepted standards of practice for disease processes and conditions. If the nurse administers a medication the health-care provider has prescribed and it harms the client, the nurse could be held accountable. Remember that the nurse is a client advocate Synthroid is a daily medication and can be administered at any time. 2. Protonix is a daily medication and can be administered at any time. 3. Tylenol is for mild to moderate pain; this client would require a more potent analgesic. The nurse should assess the client s medications and discuss other medications with the HCP. This would not be the first medication to administer. 4. Pancreatic enzymes are administered with every meal and snack. The nurse should administer this medication so the medication and the breakfast foods arrive in the small intestine simultaneously The nurse is following a correct procedure for administering medications through a nasogastric tube that is connected to suction. The tube should remain clamped for 1 hour before it is reconnected to suction. 2. The nurse followed correct procedure; there is no reason to notify the manager. 3. The nurse is following a correct procedure for administering medications through a nasogastric tube that is connected to suction. The tube should remain clamped for 1 hour before it is reconnected to suction to allow the medication to be absorbed. 4. The medication is ordered to be administered through the tube, not orally The Librium may act as an adjunct to pain relief, but this is not the reason for prescribing the medication to this client. 2. Librium is useful in preventing delirium tremens in clients withdrawing from alcohol. The majority of clients diagnosed with chronic pancreatitis (75%) are middle-aged males who also have chronic alcoholism. 3. Librium may have some antiemetic properties, but this is not the reason for prescribing the medication to this client. 4. Librium can cause drowsiness, but it is not the drug of choice as a sleep aid for a client who is NPO Clients should be asked to rate their pain on a scale so the nurse can objectively evaluate the effectiveness of the interventions. 2. The nurse abides by the five rights of medication administration, including the right time. Pain medication is prescribed at specific time intervals. The nurse must make sure the time interval has passed and it is time for more medication. 3. A client diagnosed with severe acute pancreatitis will be NPO, and Vicodin is an oral narcotic medication. The nurse would administer an IV medication. 4. The client should be placed in a semi- Fowler s position to relieve pressure on the abdomen, thereby decreasing the client s pain. 5. There is no indication that the client requires oxygenation at this time Blood glucose levels should be monitored every 4 6 hours, not daily. 2. TPN requires a central line for administration, not a peripheral line. The high concentration of dextrose in TPN causes phlebitis in peripheral veins.

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