Endocrine practice questions

Question 1

A 58-year-old client with type 2 diabetes is scheduled for an elective total hip arthroplasty tomorrow morning. Which of the following interventions should the nurse include in the client's plan of care to reduce the risk of a surgical site infection?

Accepted Answer

A: Maintain the client's temperature at 96.8° F (36° C) or higher during and after the surgery; C: Maintain the blood glucose at less than 200 mg/dL before and after the surgery; D: Remove hair at the incision site with electric clippers only if the hair interferes with the surgery; E: Instruct the client to shower with chlorhexidine gluconate soap the night before and the morning of surgery. A surgical site infection is an infection of the incision or the deeper tissues that develops within 30 days of surgery, or within 90 days when an implant such as a hip prosthesis is placed. Most come from the client's own skin organisms, so preparing the skin and supporting the client's defenses are the main nursing tools.

A chlorhexidine shower before surgery lowers the number of bacteria on the skin. Hair is left in place unless it interferes with the procedure, and when it must be removed, clippers are used, because a razor makes tiny cuts where bacteria grow. High blood glucose weakens the white cells that fight infection, so glucose is kept at less than 200 mg/dL around the time of surgery in clients with or without diabetes. Hypothermia narrows the blood vessels in the skin and lowers the oxygen reaching the wound, so the client is kept at 96.8° F (36° C) or higher with warmed blankets or a forced-air warming device. A prophylactic antibiotic such as cefazolin is also given within 60 minutes before the incision.

Question 2

The nurse is reviewing insulins with a student. For each description, specify which insulin it fits.

Accepted Answer

Clear solution that may be given by intravenous drip: Regular; Cloudy suspension that must never go in an intravenous bag: NPH; Given with the meal tray rather than before it: Lispro; Has no peak at all: Glargine; Onset in about 30 to 60 minutes and peaks at 2 to 3 hours: Regular; Given at 0700, it is still peaking in the late afternoon: NPH; Drawn up in the same syringe as regular insulin: NPH; The fastest onset of the four: Lispro. Four insulins, and the quickest way to keep them apart is to ask two questions about each: how fast, and can it go in a vein.

Regular is the only one that goes in a vein, because it is a clear solution rather than a suspension. It peaks 2 to 3 hours after a subcutaneous dose. NPH is the cloudy one, a suspension of particles that would not be safe in a vein at all, and its peak is a broad window rather than a point.

Lispro is the fastest. Fifteen minutes to onset is why it goes in with the tray. Glargine is the slowest and the flattest, with no peak, which is what makes it background insulin and what makes it safe overnight.

Every clinical decision in this topic comes out of those four profiles. Which one can be titrated in an emergency, which one needs food in front of the client, which one the nurse plans an afternoon snack around, and which one is never used to correct a high reading.

Question 3

The nurse is caring for a 27-year-old client with type 1 diabetes who uses an insulin-to-carbohydrate ratio of 1 unit of insulin lispro for every 15 g of carbohydrate. The client also has a correction dose of 1 unit for every 50 mg/dL above a target glucose of 150 mg/dL. Before lunch, the capillary glucose is 250 mg/dL. The lunch tray holds a turkey sandwich on 2 slices of bread (30 g of carbohydrate), 1 cup of fat-free milk (12 g), 1 small apple (15 g), and a garden salad with oil and vinegar (3 g). How many units of insulin lispro should the nurse administer? Record your answer using a whole number.

Accepted Answer

6. An insulin-to-carbohydrate ratio matches the mealtime dose to the carbohydrate the client is about to eat. Carbohydrate is the nutrient that raises the glucose after a meal, so the dose follows the grams of carbohydrate, not the size of the plate. Protein and fat in the turkey and the salad dressing add very little.

The correction dose is a separate piece. It brings a glucose that is already high back toward the target, and it is added to the meal dose. This client starts lunch 100 mg/dL above target, so the client needs 2 extra units on top of the 4 units for the food.

Rapid-acting insulin such as lispro starts working in about 15 minutes, so the nurse gives it within 15 minutes of the meal and confirms the client will eat the tray.

Question 4

A client with diabetes reports a blood glucose of 58 mg/dL and asks whether a chocolate bar would work as well as glucose tablets. Which response by the nurse is correct?

Accepted Answer

D: "The fat in chocolate slows absorption, so it raises your sugar too slowly.". Chocolate has sugar in it, and it also has a great deal of fat, and fat slows gastric emptying. That means the sugar arrives late. When the treatment for a low has to work within 15 minutes, late is the same as not working, and the client keeps falling while the chocolate is still in the stomach.

The treatment for a low is something that is almost pure fast carbohydrate and has little or no fat: glucose tablets, juice, regular soda, or honey. Fat and protein have a place a few minutes later, in the snack that stops the low coming back, and not in the rescue itself.

Question 5

A client with diabetes is pale, sweating and shaking. Which findings should the nurse expect to accompany these? Select all that apply.

Accepted Answer

A: Staggering, unsteady gait; B: Slurred speech; D: Slowed reaction time. Hypoglycemia is a blood glucose level below 70 mg/dL, so the brain and body are not getting enough fuel. If it is not treated quickly, it can lead to confusion, seizures and loss of consciousness.

The pale skin, sweating and shaking come from the body releasing adrenaline. At the same time, the brain is starved of glucose and starts to act drunk, causing an unsteady gait, slurred speech and slowed reactions. That is why A, B and D are correct.

Question 6

The nurse is adjusting the regular insulin infusion (100 units in 100 mL of 0.9% sodium chloride) for a 23-year-old client with diabetic ketoacidosis who weighs 82 kg. The glucose has decreased to 196 mg/dL, and 5% dextrose has been added to the IV fluid. The unit protocol now directs the nurse to reduce the insulin infusion to 0.05 units/kg/hr. How many mL/hr should the nurse set the IV infusion pump to deliver? Record your answer using 1 decimal place.

Accepted Answer

4.1. Once the glucose falls to about 200 mg/dL and dextrose is running, many protocols lower the insulin dose to between 0.02 and 0.05 units/kg/hr. The lower dose still stops ketone production, and the dextrose keeps the glucose from dropping too far.

This client needs 4.1 units/hr. With a concentration of 100 units in 100 mL, every mL holds 1 unit, so the pump is set to deliver 4.1 mL/hr. The nurse has a second nurse independently check the new rate, because IV insulin is a high-alert medication and a decimal error can cause severe hypoglycemia.

Question 7

The nurse is reviewing home care with a 39-year-old client who has Cushing syndrome. Which statement by the client requires further teaching?

Accepted Answer

D: "I will take a hot bath every night to help with the aching in my back.". Cushing syndrome is a condition caused by too much cortisol in the body, either from the adrenal glands or from long-term corticosteroid medicine.

The bath is the statement to correct, and the aching back is the reason. Back pain in a client with Cushing syndrome is a possible vertebral fracture from steroid-induced osteoporosis, and it is a finding to report rather than a symptom to soak.

The other three are the client getting it right. A soft toothbrush and an electric razor protect skin and gums that bruise and bleed easily, keeping away from infection matters because the immune response is blunted, and sudden back pain is exactly what they should report.

Question 8

The nurse is preparing a 34-year-old client with central diabetes insipidus for discharge with desmopressin 0.2 mg orally twice daily. Which of the following instructions should the nurse include?

Accepted Answer

B: Drink fluids when thirsty rather than on a fixed schedule; C: Report a headache, nausea, or new confusion to the provider; D: Weigh yourself each morning and report a sudden gain. Central diabetes insipidus is a shortage of antidiuretic hormone from the posterior pituitary. Desmopressin replaces it, so the kidneys hold water again and the urine output falls to normal. The urine output is normal because the medication is working, not because the disease has gone away.

The main risk on desmopressin is too much water. A client who keeps drinking the large volumes needed before treatment will retain that water and dilute the sodium. Drinking to thirst lets the body guide intake. A sudden weight gain shows water is being held, and headache, nausea, and confusion are early signs of a falling sodium.

Question 9

At 0800 the nurse reviews the morning data for a 78-year-old client with heart failure, atrial fibrillation, and hypothyroidism before the 0900 medication pass. The apical pulse is 54/min and irregular, the BP is 136/82 mm Hg, the potassium is 4.1 mEq/L, and the INR is 4.6. For each potential intervention, click to specify if the intervention is indicated or not indicated for the care of the client.

Accepted Answer

Give lisinopril 10 mg orally: Indicated; Give digoxin 0.125 mg orally: Not indicated; Give levothyroxine 100 mcg orally before breakfast: Indicated; Give warfarin 5 mg orally: Not indicated; Give furosemide 40 mg orally: Indicated. A hold parameter is a value that tells the nurse a scheduled dose could harm the client today. Before each medication the nurse checks the finding it affects, and when that finding is out of the safe range the dose is held and the health care provider is notified.

Digoxin slows conduction through the atrioventricular node. An apical pulse, counted for a full minute, under 60/min in an adult means the dose is held, because digoxin could slow the heart further and bradycardia can be an early sign of toxicity. Warfarin is held when the INR is above the client's target range, usually 2 to 3 in atrial fibrillation, because an INR of 4.6 means a high risk of bleeding.

The other three medications are safe today. A BP of 136/82 mm Hg and a potassium of 4.1 mEq/L allow both furosemide and lisinopril, and levothyroxine is given on an empty stomach before breakfast. A slow heart rate is not a reason to hold levothyroxine. Tachycardia, palpitations, or chest pain would be.

Question 10

A student asks why dextrose is given with the insulin when treating a high potassium. Which response by the nurse is correct?

Accepted Answer

D: "The dextrose stops the blood sugar falling once the insulin acts.". Insulin is being given to a client who does not need it for their blood sugar. It is being used for its side effect, which is that it moves potassium into cells alongside glucose, and the dextrose is there so that the blood sugar does not fall while it works.

That is also why the blood sugar is monitored afterward. The insulin goes on working after the dextrose is used up, so hypoglycemia is a real risk in the hour or two following the dose.

Endocrine practice questions.