A 64-year-old client with type 2 diabetes is seen for an annual visit. Current medication: metformin 1,000 mg PO twice daily. Today's results: A1C 8.6% (7.9% six months ago), eGFR 38 mL/min/1.73 m2 (52 one year ago), urine albumin-to-creatinine ratio 42 mg/g (first elevated result), BP 132/80 mm Hg. Dilated eye exams in each of the last 2 years showed no retinopathy. At the last visit, the client could not feel the monofilament on either foot. Which actions should the nurse anticipate in the plan of care? Select all that apply.

Quick answer
Inspect the feet every visit, review a lower metformin dose, and recheck the A1C in 3 months (options 1, 5, 6).

Why this is correct
Each correct action comes from a detail of this client. Monofilament loss is loss of protective sensation, which moves foot inspection from annual to every visit. With an eGFR of 30 to 44, ADA advises reassessing benefit and reducing the metformin dose (commonly to a maximum of 1,000 mg/day); metformin is stopped only when eGFR falls below 30. An A1C of 8.6% that rose from 7.9% is not at goal, so testing moves to about every 3 months.

Easy analogy or mental picture
Think of three dials, each turned by one reading: the monofilament turns the foot-check dial up, the eGFR turns the metformin dial down, and the rising A1C turns the lab-check dial faster.

Memory hook
Numb feet = look every visit; eGFR 30-44 = cut metformin; under 30 = stop.

NCLEX decision rule
Adjust routine screening intervals to the client's current data; a normal history only extends intervals when control is good.

Why the other choices are wrong
Holding metformin until eGFR exceeds 45 (option 4) is tempting because 45 is the threshold for starting metformin, but for a client already taking it, eGFR 30 to 44 means dose reduction; stopping is for eGFR below 30. Extending eye exams to every 2 years (option 3) is tempting after two normal exams, but that option applies only when glycemia is well controlled, and this A1C is 8.6% and rising. Restricting protein to 0.6 g/kg (option 2) is an older kidney-diet teaching; ADA recommends about 0.8 g/kg/day for non-dialysis kidney disease because lower intake risks malnutrition.