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Difficulty: Very hardPharmacological and Parenteral Therapies

A client admitted with diabetic ketoacidosis (DKA) is receiving a continuous intravenous (IV) infusion of regular insulin at 0.1 units/kg/hr0.1\text{ units/kg/hr}. The client's baseline serum potassium was 5.4 mEq/L5.4\text{ mEq/L} and blood glucose was 680 mg/dL680\text{ mg/dL}. Four hours later, the current blood glucose is 245 mg/dL245\text{ mg/dL}, and the cardiac monitor reveals new-onset premature ventricular contractions and prominent U waves. The current primary IV fluid is 0.9%0.9\% sodium chloride infusing at 150 mL/hr150\text{ mL/hr}. Based on these findings, which of the following is the priority nursing action?

  1. Initiate a primary IV fluid containing 5%5\% dextrose and verify the prescription for a continuous intravenous potassium chloride additive.Answer
  2. B
    Discontinue the continuous intravenous regular insulin infusion to prevent impending hypoglycemia.
  3. C
    Administer the prescribed intravenous potassium chloride as a rapid secondary IV piggyback over 15 minutes.
  4. D
    Administer prescribed intravenous calcium gluconate to stabilize the myocardial conduction system.

Answer

The priority is to change the primary IV fluid to include 5%5\% dextrose and begin continuous intravenous potassium replacement.
In the management of diabetic ketoacidosis (DKA), continuous intravenous insulin shifts potassium intracellularly, frequently causing severe hypokalemia. The presence of prominent U waves and premature ventricular contractions confirms this life-threatening complication, necessitating immediate potassium replacement. Concurrently, when the client's blood glucose falls below 250 mg/dL250\text{ mg/dL} (13.9 mmol/L13.9\text{ mmol/L}), dextrose must be added to the primary IV fluid. This prevents hypoglycemia and allows the life-saving insulin infusion to continue running until the metabolic acidosis and anion gap are fully resolved. The correct action synthesizes both of these critical parenteral therapy protocols.

Step-by-Step Solution

1
Analyze the current blood glucose level of 245 mg/dL245\text{ mg/dL}.
The blood glucose has fallen below the critical threshold of 250 mg/dL250\text{ mg/dL}.
Standard DKA protocols require adding dextrose to IV fluids when glucose falls below 250 mg/dL250\text{ mg/dL} to prevent hypoglycemia, allowing the continuous insulin infusion to remain active until the ketoacidosis fully resolves.
2
Interpret the electrocardiogram changes (premature ventricular contractions and prominent U waves).
These ECG changes are classic clinical indicators of severe hypokalemia.
Continuous IV insulin therapy drives both glucose and potassium from the intravascular space into the intracellular space, rapidly depleting serum potassium levels even if baseline values were normal or elevated.
3
Synthesize the findings to determine the priority pharmacological intervention.
The client requires concurrent administration of IV dextrose (to safely continue insulin) and IV potassium chloride (to treat the arrhythmias).
Addressing the life-threatening electrolyte imbalance while maintaining the correct fluid transition is the cornerstone of safe DKA parenteral therapy.

Key Concept

Pharmacological Management of DKA: Fluid Transition and Electrolyte Shifts
Estimated Time:2m 0s
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Topics

Pharmacological and Parenteral Therapies

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