A nurse is managing the care of a client admitted to the intensive care unit with severe diabetic ketoacidosis (DKA). The client's initial blood glucose is 680 mg/dL (37.7 mmol/L), pH is 7.15, and blood pressure is 88/54 mm Hg. Arrange the following nursing interventions in the correct sequence of execution from first to last.
- 1Initiate a rapid intravenous infusion of 0.9% sodium chloride.
- 2Review the initial basic metabolic panel for the serum potassium level.
- 3Start a continuous intravenous infusion of regular insulin.
- 4Append 5% dextrose to the maintenance intravenous fluids.
- 5Administer the first dose of subcutaneous long-acting insulin.
Answer
The correct sequence is: fluid resuscitation, potassium evaluation, insulin infusion initiation, addition of dextrose to fluids, and transition to subcutaneous insulin.
In diabetic ketoacidosis, severe osmotic diuresis leads to profound dehydration and potential hypovolemic shock. Therefore, the absolute first priority is fluid resuscitation with isotonic saline to restore perfusion. Once fluids are running, the nurse must ensure the serum potassium is greater than 3.3 mEq/L before giving insulin, as insulin drives potassium back into the cells and can trigger lethal hypokalemia. Following potassium verification, a continuous regular insulin infusion is started to halt ketone production and resolve the acidosis. As the blood glucose falls to around 200-250 mg/dL (11.1-13.9 mmol/L), 5% dextrose is added to the IV fluids to prevent hypoglycemia and cerebral edema while the insulin continues to clear the remaining ketones. Finally, once the acidosis has completely resolved and the client can tolerate oral intake, a transition to subcutaneous insulin is initiated before stopping the IV insulin.
Step-by-Step Solution
Key Concept
The physiological stabilization sequence for diabetic ketoacidosis requires treating hypovolemia first, then securing safe electrolyte levels before reversing the acidosis with insulin.