Chapter 13: Drug Therapy for Diabetes
Workman & LaCharity: Understanding Pharmacology: Essentials for Medication
Safety, 2nd Edition
MULTIPLE CHOICE
BASIC CONCEPTS
1. 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.
DIF: Cognitive Level: Remembering
REF: p. 220
2. By which action does insulin lower blood glucose levels?
a. Enhancing the enzymes that break down glucose
b. Helping glucose to move from the blood into cells
c. Converting glucose into proteins in the liver and brain
d. Converting glycogen into glucose in the liver and brain
ANS: B
When insulin binds to insulin receptors on cells, the cells’ membranes become more open
(permeable) to glucose and glucose transport proteins in the cell membranes become more
active. The overall result is movement of glucose into the cells, which lowers blood glucose
levels.
DIF: Cognitive Level: Remembering
REF: p. 220
3. Which term means an elevated blood sugar (glucose) level?
a. Glycogen
b. Euglycemia
c. Hypoglycemia
d. Hyperglycemia
ANS: D
Glycogen is a stored form of human carbohydrate. Euglycemia means a blood sugar level
within the normal range. Hypoglycemia is a lower than normal blood sugar level.
DIF: Cognitive Level: Remembering
REF: p. 210
4. Which hormone has an action opposite to the action of insulin?
a. Glycogen
b. Glucagon
c. Hemoglobin A1c
d. Adenosine triphosphate
ANS: B
Glucagon, which is known as the hormone of starvation, is secreted from the alpha cells of the
pancreas when blood glucose levels are lower than normal. Glucagon goes to the liver and
triggers the breakdown of glycogen and release of glucose into the blood, raising the blood
glucose level. These actions are exactly the opposite of insulin’s actions.
DIF: Cognitive Level: Remembering
REF: p. 212
5. What is the main reason that insulin is needed as drug therapy for people who have type 1
diabetes?
a. The beta cells of the pancreas no longer make insulin.
b. The alpha cells of the pancreas no longer make insulin.
c. The beta cells of the pancreas make too much glucagon.
d. The alpha cells of the pancreas make too much glucagon.
ANS: A
With type 1 diabetes, the beta cells of the pancreas are destroyed and no longer produce any
insulin. Insulin is necessary for life, so drug therapy for type 1 diabetes requires insulin.
People who have type 2 diabetes often continue to secrete insulin from their beta cells, thus
extra insulin may not be needed. Drugs for this condition often work by forcing the beta cells
to release the patient’s own insulin.
DIF: Cognitive Level: Remembering
REF: p. 212
6. 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.
DIF: Cognitive Level: Remembering
REF: p. 215
7. Which problem associated with insulin therapy and diabetes is intensified for a patient who is
also prescribed warfarin (Coumadin) or a beta adrenergic blocker?
a. Hypoglycemia
b. Nausea/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 patient’s 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/vomiting as side effects.
DIF: Cognitive Level: Remembering
REF: p. 219
8. Which drug therapy class is considered the treatment of choice for people who have
gestational diabetes mellitus?
a. Insulin
b. Insulin sensitizers
c. Thiazolidinediones
d. Alpha-glucosidase inhibitors
ANS: A
Insulin is the only class of antidiabetic drugs approved for use in patients who have
gestational diabetes mellitus. This type of diabetes is more difficult to control and with other
agents tends to have more periods of hypoglycemia and hyperglycemia.
DIF: Cognitive Level: Remembering
REF: p. 219
9. What makes insulin a “high-alert” drug?
a. Many people are very allergic to insulin.
b. Serious harm can occur if the wrong dose is given.
c. If too much insulin is given, the respiratory system is depressed.
d. If too much insulin is given, the blood glucose level could climb to dangerously
high levels.
ANS: B
Insulin as a drug works very quickly. Great harm can come to a patient who receives it and
does not have diabetes. Also, if too much of it is given to a patient who does have diabetes,
the patient can become severely hypoglycemic and die. If too little insulin is given to a patient
who has diabetes, blood glucose levels remain too high and cause organ damage.
DIF: Cognitive Level: Remembering
REF: p. 214
10. Which type of insulin has the shortest duration of action?
a. Rapid-acting insulin
b. Short-acting insulin
c. Intermediate-acting insulin
d. Long-acting insulin
ANS: A
Not only does rapid-acting insulin have a quick onset of action, it also has a very short
duration of action and is inactivated quickly.
DIF: Cognitive Level: Remembering
REF: p. 214
11. Which problem is a common side effect of insulin therapy?
a. Increased blood clotting
b. Decreased blood clotting
c. Injection site infection
d. Foot ulcer formation
ANS: C
Insulin therapy does not affect blood clotting. Foot ulcer formation occurs as a result of
diabetes and not because of insulin therapy. Insulin is delivered as an injection and people
with diabetes have a greater risk for infection. So, the only side effect for insulin on this list is
injection site infection.
DIF: Cognitive Level: Remembering
REF: p. 215
12. Which problem is a major symptom of low blood sugar levels?
a. Hypertension
b. Flushed skin
c. Weight gain
d. Confusion
ANS: D
The brain depends on a constant supply of glucose in the blood for proper function. When
blood glucose levels become too low, the brain does not function properly.
DIF: Cognitive Level: Remembering
REF: p. 215
13. Which body area should never be used to inject insulin?
a. The actual umbilicus
b. The outer thighs
c. The upper arms
d. The lower back
ANS: A
The most preferred injection site is within a 2-inch circumference around (but not in) the
umbilicus. The skin of the umbilicus is thick and contains fewer blood vessels. Insulin
absorption would be slow here and the area is at greater risk for infection.
DIF: Cognitive Level: Remembering
REF: p. 217
14. What is the action of the biguanide class of antidiabetic drugs that lowers blood glucose
levels?
a. Directly forcing beta cells to release more insulin
b. Inhibiting the enzyme that breaks down insulin
c. Preventing the breakdown of glycogen into glucose
d. Increasing the person’s need for glucose
ANS: C
The biguanides (metformin) work in two ways to lower blood glucose levels. They decrease
conversion of glycogen into glucose within the liver and they increase the sensitivity of the
insulin receptor to binding insulin. The sulfonylureas and the meglitinide analogues force beta
cells to release more insulin. None of the drugs inactivate the enzyme that breaks down
insulin, nor do they increase the person’s need for glucose.
DIF: Cognitive Level: Remembering
REF: p. 222
15. Which oral antidiabetic drug belongs to the alpha-glucosidase inhibitor class?
a. Acarbose (Precose)
b. Glyburide (Diabeta)
c. Nateglinide (Starlix)
d. Pioglitazone (Actos)
ANS: A
Acarbose (Precose) belongs to the alpha-glucosidase inhibitor class. Glyburide (Diabeta)
belongs to the Insulin Secretagogues class. Nateglinide (Starlix) belongs to the Meglitinides
class and Pioglitazone (Actos) belongs to the Thiazolidinediones class.
DIF: Cognitive Level: Remembering
REF: p. 221
16. Which class of oral antidiabetic drug can cause severe hypoglycemia when used alone?
a. Alpha-glucosidase inhibitors
b. Thiazolidinediones
c. Sulfonylureas
d. Biguanides
ANS: C
The sulfonylurea drugs force the beta cells of the pancreas to secrete preformed insulin. If the
patient has not eaten at a time close to when he or she took the drug, blood glucose levels
could drop sharply and endanger the patient. Other drugs on this list do not increase insulin
production and are not likely to cause hypoglycemia when used as a single agent.
DIF: Cognitive Level: Remembering
REF: p. 222
17. Which drug used to treat diabetes by increasing incretins and amylin is taken orally?
a. Exenatide (Byetta)
b. Liraglutide (Victoza)
c. Pramlintide (Symlin)
d. Sitagliptin (Januvia)
ANS: D
Exenatide, liraglutide, and pramlintide are all administered by subcutaneous injection. Only
sitagliptin is an oral agent.
DIF: Cognitive Level: Remembering
REF: p. 222
18. Which antidiabetic drug can increase the risk for pancreatitis?
a. Alogliptin (Nesina)
b. Glyburide (Diabeta)
c. Metformin (Glucophage)
d. Dapagliflozin (Farxiga)
ANS: D
Dapagliflozin is a drug from the sodium-glucose cotransport inhibitor class. Drugs from this
class increase the risk for pancreatitis.
DIF: Cognitive Level: Remembering
REF: p. 222
ADVANCED CONCEPTS
19. 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 body’s 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 body’s cellular reactions.
DIF: Cognitive Level: Understanding
REF: p. 210
20. 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).
DIF: Cognitive Level: Understanding
REF: p. 212
21. 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, Alzheimer’s 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.
DIF: Cognitive Level: Understanding
REF: p. 213
22. How do type 1 and type 2 diabetes differ from each other?
a. Type 1 diabetes develops in people under 40 years old, whereas type 2 diabetes
develops only in older people.
b. Type 2 diabetes develops in people under 40 years old, whereas type 1 diabetes
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 patient’s 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.
DIF: Cognitive Level: Understanding
REF: pp. 212-213
23. 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.
DIF: Cognitive Level: Understanding
REF: p. 213
24. 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 your 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.
DIF: Cognitive Level: Applying or Higher
REF: p. 210
25. Which statement about insulin glargine is true?
a. It has no time to peak action.
b. It normally has a cloudy appearance.
c. It can be mixed with any other insulin type.
d. It should be avoided as therapy for anyone who has a sulfa allergy.
ANS: A
Insulin glargine has a formulation that makes it long-acting and slow-releasing. As a result,
the blood levels are low and the action is prolonged. It has no particular time to peak action. It
normally has a clear, not a cloudy appearance and should not be mixed with most other insulin
types. It does not contain sulfa and does not trigger an allergic reaction in anyone who has a
sulfa allergy.
DIF: Cognitive Level: Understanding
REF: p. 214
26. Which precaution is most important to teach patients who have any type of diabetes about
alcohol use?
a. “Be sure to take your antidiabetic drug or drugs 15 minutes before drinking any
alcohol.”
b. “Only drink alcohol right before bedtime because it will make you drowsy.”
c. “Increase your water intake whenever you drink alcohol.”
d. “Only drink alcohol with a meal or shortly after a meal.”
ANS: D
Drinking alcoholic beverages leads to hypoglycemia. To prevent hypoglycemia, alcohol
consumption should be limited to no more than one serving per day and should be taken either
with a meal or very shortly after a meal.
DIF: Cognitive Level: Applying or Higher
REF: p. 223
27. What is the most important action 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 patient’s meal or snack is already on the unit
d. Holding the dose if the patient’s 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 patient’s blood glucose level is under 110
mg/dL, the premeal dose is still given.
DIF: Cognitive Level: Applying or Higher
REF: p. 216
28. When 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.
DIF: Cognitive Level: Applying or Higher
REF: p. 217
29. A patient is receiving an injection of Humulin 70/30 at 7:00 a.m. At what time should you
expect the peak action for this drug?
a. Between 7:30 a.m. and 8:00 a.m.
b. Between 9:00 a.m. and 11:00 a.m.
c. Between 1:00 p.m. and 5:00 p.m.
d. Between 4:00 p.m. and 11:00 p.m.
ANS: C
Humulin 70/30 contains 70% human insulin isophane and 30% human regular insulin. It is
classified as “intermediate-acting” and has a peak action time between 6 and 10 hours.
DIF: Cognitive Level: Applying or Higher
REF: p. 214
30. Which patient taking insulin is at greatest risk for developing hypoglycemia?
a. 38-year-old who is pregnant with twins
b. 50-year-old who drinks 6 to 8 cups of coffee daily
c. 55-year-old who takes hormone replacement therapy for menopausal symptoms
d. 70-year-old who also takes warfarin (Coumadin) daily for atrial fibrillation
ANS: D
Older adults are at greater risk for hypoglycemia while on insulin therapy. In addition,
warfarin increases the hypoglycemic response.
DIF: Cognitive Level: Applying or Higher
REF: p. 219
31. With which patient should you be prepared to administer glucagon as a drug?
a. 60-year-old with type 2 diabetes who has renal impairment
b. 42-year-old who has a blood glucose level of 25 mg/dL
c. 28-year-old who has type 2 diabetes and is in diabetic ketoacidosis
d. 10-year-old with a fasting blood glucose of 87 mg/dL
ANS: B
As a hormone or a drug glucagon has actions that are opposite insulin. It is given when
hypoglycemia is severe to convert liver glycogen into glucose and release into the blood to
raise the blood glucose level.
DIF: Cognitive Level: Applying or Higher
REF: p. 211
32. After gently rotating a vial of isophane insulin NPH (Humulin N), you note that the drug has a
cloudy appearance. What step should you 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.
DIF: Cognitive Level: Applying or Higher
REF: p. 216
33. Why should you 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.
DIF: Cognitive Level: Understanding
REF: p. 217
34. When administering insulin by subcutaneous injection to a very thin patient, which adjustment
in injection technique should you 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 patient’s subcutaneous tissue and allow the drug to enter a muscle, which could then be
absorbed too rapidly.
DIF: Cognitive Level: Applying or Higher
REF: p. 217
35. 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 do you 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.
DIF: Cognitive Level: Applying or Higher
REF: p. 217
36. 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 your best first action?
a. Prepare to administer intravenous (IV) glucose immediately.
b. Check the patient’s 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 patient’s 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.
DIF: Cognitive Level: Applying or Higher
REF: p. 218
37. Which blood laboratory test result indicates 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.
DIF: Cognitive Level: Applying or Higher
REF: p. 210
38. What is the most important precaution 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.
DIF: Cognitive Level: Applying or Higher
REF: p. 219
39. An older patient with diabetes is visually impaired and asks if syringes can be prefilled and
stored for use later. What is your 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.
DIF: Cognitive Level: Applying or Higher
REF: p. 224
40. A patient who has been self-injecting insulin for 10 years now has warmth, redness, and pain
at the injection site. What is your 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.
DIF: Cognitive Level: Applying or Higher
REF: p. 224
41. 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.
DIF: Cognitive Level: Understanding
REF: p. 219
42. 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.
DIF: Cognitive Level: Understanding
REF: p. 220
43. When teaching a patient newly diagnosed with type 2 diabetes who is prescribed to take
miglitol (Glyset) as antidiabetic therapy, which instruction is most important?
a. “Rotate the injection site on a weekly basis.”
b. “Take this drug with the first bite of your meal.”
c. “Do not mix this drug in the same syringe as insulin.”
d. “Be sure to take this drug at the usual time even if your meal is delayed.”
ANS: B
Miglitol is an oral antidiabetic drug from the alpha-glucosidase inhibitor class. Its action is to
slow the digestion of starches and other carbohydrates in the intestinal tract. In order to be
effective, it must be taken at the beginning of a meal.
DIF: Cognitive Level: Applying or Higher
REF: p. 221
44. 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 your best action?
a. Assess the patient’s blood glucose level and prepare to administer intravenous (IV)
glucose.
b. Assess the patient’s 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.
DIF: Cognitive Level: Applying or Higher
REF: p. 222
45. By which action do the sodium-glucose cotransport inhibitors lower blood glucose levels?
a. Inhibiting the conversion of glucose to glycogen in the liver
b. Inhibiting the conversion of glycogen to glucose in the liver
c. Increasing the sensitivity of insulin receptors to insulin
d. Increasing the renal excretion of filtered glucose
ANS: D
The sodium-glucose cotransport inhibitors inhibit the reabsorption of filtered glucose in the
kidney so that more is removed from the body in the urine. It has no action on liver glucose or
glycogen, and does not increase insulin receptor sensitivity.
DIF: Cognitive Level: Understanding
REF: p. 220
46. A patient newly diagnosed with type 2 diabetes who is prescribed rosiglitazone (Avandia) has
all the following health problems. For which problem do you 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.
DIF: Cognitive Level: Understanding
REF: p. 222
47. Which blood laboratory test result is most important 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 (LDH)
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 IU/L.
DIF: Cognitive Level: Applying or Higher
REF: p. 224
48. What precaution do you 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.
DIF: Cognitive Level: Applying or Higher
REF: p. 224
49. 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 your 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.
DIF: Cognitive Level: Applying or Higher
REF: p. 225
50. A patient with type 2 diabetes is prescribed nateglinide (Starlix). Which statement indicates
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.
DIF: Cognitive Level: Applying or Higher
REF: p. 220
51. A patient who usually takes metformin (Glucophage) was switched to insulin immediately
following an angiogram. Which patient finding indicates it is safe for the patient to switch
back to metformin?
a. 24-hour urine output greater than 2 L
b. International normalized ratio is now less than 1.2
c. Weight is unchanged from that of 1 month ago
d. Fasting blood glucose level was less than 90 mg/dL for 2 days in a row
ANS: A
Metformin can cause renal impairment when the patient is also exposed to radio-opaque dyes
and some anesthetic agents. This can happen up to 48 hours after the exposure. The drug can
be restarted after 48 hours if the kidney function, as measured by an adequate urine output, is
normal.
DIF: Cognitive Level: Applying or Higher
REF: p. 222
52. A patient who is prescribed glyburide (DiaBeta) asks if having a glass of wine once a week is
okay. What is your 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.
DIF: Cognitive Level: Applying or Higher
REF: p. 223
53. 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 do you 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 IU/L
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.
DIF: Cognitive Level: Applying or Higher
REF: p. 222
54. Which fasting blood glucose level indicates that the antidiabetic drug 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.
DIF: Cognitive Level: Understanding
REF: p. 210
55. Which assessment precaution is most important 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.
DIF: Cognitive Level: Applying or Higher
REF: p. 222
56. 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 infant’s 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 infant’s 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.
DIF: Cognitive Level: Understanding
REF: p. 224
57. A patient who has been prescribed sitagliptin (Januvia) calls the clinic and reports swelling of
the face, lips, and tongue. What is your 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 patient’s 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.
DIF: Cognitive Level: Applying or Higher
REF: p. 224
58. A patient who has been prescribed exenatide (Byetta) reports a weight loss of 11 lb in the last
month. What is your 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 of these actions help the patient eat less and lose weight, a
desired outcome for patients with type 2 diabetes. An 11 lb weight loss in 1 month is not
excessive and no action needs to be taken at this time.
DIF: Cognitive Level: Applying or Higher
REF: pp. 222-223
COMPLETION
ADVANCED CONCEPTS
1. A patient is prescribed repaglinide (Prandin) 3 mg. The drug available is repaglinide 0.5
mg/tablet. How many tablets do you administer to the patient for a correct dose?
_____ tablet(s)
ANS:
6
Want 3 mg, Have 0.5 mg/tablet.
3/0.5 = 6 × 1 tablet = 6 tablets.
DIF: Cognitive Level: Applying or Higher
REF: p. 220
ORDERING
ADVANCED CONCEPTS
1. A patient is to receive 15 units of NPH insulin and 20 units of regular insulin in the same
syringe. In what order should you 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.
DIF: Cognitive Level: Applying or Higher
REF: p. 217, Box 13-4