# 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.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=617269&lang=en  
> language: en  
> subject: Health Screening  
> category: HPM

## Question

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.

1

Inspect both feet for skin breakdown at every clinic visit

2

Limit dietary protein intake to 0.6 g/kg of body weight daily

3

Lengthen the dilated eye exam interval to every 2 years

4

Hold metformin until the eGFR is again above 45 mL/min

5

Review a lower metformin dose with the prescribing provider

6

Recheck the A1C in 3 months rather than in 6 months

## Explanation

Loss of monofilament sensation means the feet must be inspected at every visit, an eGFR of 38 on full-dose metformin calls for a dose reduction rather than a stop, and an A1C that is above goal and rising calls for quarterly testing. Stopping metformin is the rule below an eGFR of 30, not 38. Extending eye exams to every 2 years is allowed only when glycemia is well controlled, and ADA does not recommend restricting protein below 0.8 g/kg/day in non-dialysis kidney disease.

## In-depth explanation

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.

References
1American Diabetes Association: Standards of Care in DiabetesMetformin dosing by eGFR, A1C testing frequency, retinopathy and foot screening intervals, protein intake in CKD

## Clinical scenario

Scenario
An adult with type 2 diabetes has a rising A1C, an eGFR that fell from 52 to 38, a first elevated albuminuria result, two normal eye exams, and loss of protective sensation on both feet.

## Key concepts

- **Loss of protective sensation** — Inability to feel a 10-g monofilament, which identifies a foot at high risk for ulceration.
- **eGFR** — Estimated glomerular filtration rate, used to stage kidney function and adjust renally cleared drugs such as metformin.
- **Urine albumin-to-creatinine ratio** — A spot urine test for albuminuria; 30 mg/g or higher is elevated and should be confirmed on repeat testing.

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