DIABETES MELLITUS EXAM

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
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 clients 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. 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

9. Answer: 3. 16-20 hours

Answers and Rationale

1. Answer: 4. Do all of the above 10. Answer: 2. Signs of hypoglycemia earlier than
expected.

2. Answer: 1. Hypoglycemia
11. Answer: 2. 6-14 hours after administration

3. Answer: 3. 126mg/dl
NPH is intermediate acting insulin. The onset of

4. Answer: 3. 2-3 weeks action is 1-2 hours, it peaks in 6-14 hours, and it’s
duration of action is 24 hours. Hypoglycemic
5. Answer: 2. Diaphoresis reactions most likely occur during peak time.

6. Answer: 4. Palpation for increased pulse volume 12. Answer: 1. Gives small continuous dose of
in the arteries of the lower extremities regular insulin subcutaneously, and the client can
self-administer a bolus with an additional dosage
7. Answer: 3. 50-60% from the pump before each meal.

8. Answer: 2. 1330 and 1930 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 accompanied by fluids and electrolytes, causing
with additional dosage from the pump before each osmotic diuresis leading to dehydration. This fluid
meal as needed. Regular insulin is used in an insulin loss must be replaced when it becomes severe.
pump. An external pump is not attached surgically to Options B, C, and D are not related specifically to the
the pancreas. issue of the question.

13. Answer: 1. Elevated blood glucose level and a 16. Answer: 1. Administer regular insulin
low plasma bicarbonate intravenously

In diabetic acidosis, the arterial pH is less than 7.35. Lack (absolute or relative) of insulin is the primary
plasma bicarbonate is less than 15mEq/L, and the cause of DK1. Treatment consists of insulin
blood glucose level is higher than 250mg/dl and administration (regular insulin), IV fluid
ketones are present in the blood and urine. The client administration (normal saline initially), and
would be experiencing polyuria, and Kussmaul’s potassium replacement, followed by correcting
respirations would be present. A comatose state may acidosis. Applying an electrocardiogram monitor is
occur if DKA is not treated, but coma would not not a priority action.
confirm the diagnosis
17. Answer: 4. Temperature
14. Answer: 4. Convey empathy, trust, and respect
toward the client. An elevated temperature may indicate infection.
Infection is a leading cause of hyperglycemic
The most appropriate intervention is to address the hyperosmolar nonketotic syndrome or diabetic
client’s feelings related to the anxiety. Administering ketoacidosis.
a sedative is not the most appropriate intervention.
The nurse should not ignore the client’s anxious 18. Answer: 1. “The best time for me to exercise is
feelings. A client will not relate to medical terms, every afternoon.”
particularly when anxiety exists.
A hypoglycemic reaction may occur in the response
15. Answer: 1. High risk for deficient fluid volume to increased exercise. Clients should avoid exercise
during the peak time of insulin. NPH insulin peaks at
Increased blood glucose will cause the kidneys to 6-14 hours; therefore afternoon exercise will occur
excrete the glucose on the urine. This glucose is
during the peak of the medication. Options B, C, and 23. Answer: 2. Human regular insulin
D do not address peak action times.
Regular insulin (Humulin R) is a short-acting insulin
19. Answer: 1. Prednisone (Deltasone) and is administered via IV with an initial dose of 0.3
units/kg, followed by 0.2 units/kg 1 hour later,
Prednisone may decrease the effect of oral followed by 0.2 units/kg every 2 hours until blood
hypoglycemics, insulin, diuretics, and potassium glucose becomes <13.9 mmol/L (<250 mg/dL). At this
supplements. point, insulin dose should be decreased by half, to
0.1 units/kg every 2 hours, until the resolution of
20. Answer: 1. Extraction of energy DKA.

Glucose catabolism is the main pathway for cellular 24. Answer: 2. “The fingertip is preferred for glucose
energy production. monitoring if hyperglycemia is suspected.”

21. Answer: 3. Fluid replacement The fingertip is preferred for glucose monitoring if
hypoglycemia, not hyperglycemia, is suspected.
As a result of osmotic pressures created by increased
serum glucose, the cells become dehydrated; the 25. Answer: 2, 3.
client must receive fluid and then insulin.
Metabolic acidosis initiates respiratory compensation
22. Answer: 2, 3, 4. in the form of Kussmaul’s respirations to counteract
the effects of ketone buildup, resulting in a lowered
Palpitations, an adrenergic symptom, occur as the PCO2. A fruity odor to the breath (acetone breath)
glucose levels fall; the sympathetic nervous system is occurs when the ketone level is elevated in
activated and epinephrine and norepinephrine are ketoacidosis.
secreted causing this response. Diaphoresis is a
sympathetic nervous system response that occurs as 26. Answer: 4. Decreased HCO3
epinephrine and norepinephrine are released.
Slurred speech is a neuroglycopenic symptom; as the The bicarbonate-carbonic acid buffer system helps
brain receives insufficient glucose, the activity of the maintain the pH of the body fluids; in metabolic
CNS becomes depressed. acidosis, there is a decrease in bicarbonate because
of an increase of metabolic acids.
27. Answer: 3. Increases blood glucose levels Because the client has diabetes, it is essential that
the blood glucose level be determined before meals
Glucagon, an insulin antagonist produced by the to evaluate the success of control of diabetes and the
alpha cells in the islets of Langerhans, leads to the possible need for insulin coverage.
conversion of glycogen to glucose in the liver.
33. Answer: 3. Monitor blood glucose closely, and
28. Answer: 3. Administer the insulin as ordered look for signs of hypoglycemia.

A value of 258mg/dl is above the expected range of When a client who has taken an oral antidiabetic
70-105 mg/dl; the nurse should administer the agent vomits, the nurse would monitor glucose and
insulin as ordered. assess him frequently for signs of hypoglycemia.
Most of the medication has probably been absorbed.
29. Answer: 1, 3, 2, 4. Therefore, repeating the dose would further lower
glucose levels later in the day. Giving insulin would
30. Answer: 2. Lispro also lower the glucose levels, causing hypoglycemic.
The client wouldn’t have hyperglycemia if the
Lispro has an immediate onset, a peak of 30-90 glyburide was absorbed.
minutes, and duration of 2-4 hours.

34. Answer: 2. Retinopathy, neuropathy, and

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

These are all chronic complications of diabetes.

An understanding of the diet is imperative for Dizziness, dyspnea on exertion, and coronary artery
compliance. A balance of carbohydrates, proteins, disease are symptoms of aortic valve stenosis.
and fats usually apportioned over three main meals Fatigue, nausea, vomiting, muscle weakness, and
and two between meals snacks needs to be tailored cardiac arrhythmias are symptoms of
to the client’s specific needs, with due regard for hyperparathyroidism. Leg ulcers, cerebral ischemic
activity, diet, and therapy. events, and pulmonary infarcts are complications of
sickle cell anemia.
32. Answer: 1. Check the client’s serum glucose level
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35. Answer: 2. Insulin lipodystrophy

Insulin lipodystrophy produces fatty masses at the 38. Answer: 4. Undiagnosed, untreated diabetes
injection sites, causing unpredictable absorption of mellitus
insulin injected into these sites.
Undiagnosed, untreated DM is one of the most
36. Answer: 4. IV bolus, followed by continuous common causes of HHNS.
infusion.
39. Answer: 1. Kussmaul’s respirations and a fruity
An IV bolus of insulin is given initially to control the odor on the breath
hyperglycemia; followed by a continuous infusion,
titrated to control blood glucose. After the client is Coma and severe acidosis are ushered in with
stabilized, subcutaneous insulin is given. Insulin is Kussmaul’s respirations (very deep but not labored
never given intramuscularly. respirations) and a fruity odor on the breath
(academia).
37. Answer: 4. Potassium
40. Answer: 3. More insulin
Insulin forces potassium out of the plasma, back into
the cells, causing hypokalemia. Potassium is needed During periods of infection or illness, diabetics may
to help transport glucose and insulin into the cells. need even more insulin to compensate for increased
Calcium, magnesium, and phosphorus aren’t affected blood glucose levels.
by insulin.