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Difficulty: MediumReduction of Risk Potential

A nurse is managing the care of a client admitted with diabetic ketoacidosis (DKA) who is receiving a continuous intravenous infusion of regular insulin. The client's current arterial blood gas (ABG) values are pH 7.31, PaCO2 32 mm Hg, and HCO3 15 mEq/L. Which actions should the nurse include in the plan of care to minimize potential complications? Select all that apply.

  1. Initiate continuous electrocardiogram (ECG) monitoring.Answer
  2. Assess capillary blood glucose levels hourly.Answer
  3. Prepare to add 5% dextrose to the intravenous fluids when blood glucose reaches 250 mg/dL (13.9 mmol/L).Answer
  4. D
    Administer prescribed intravenous sodium bicarbonate to correct the acid-base imbalance.
  5. E
    Coach the client to take slow, shallow breaths to increase the PaCO2 level.
  6. F
    Maintain the client in a flat, supine position to optimize systemic perfusion.

Answer

The correct actions are initiating continuous ECG monitoring, assessing capillary blood glucose hourly, and preparing to add 5% dextrose to intravenous fluids when glucose reaches 250 mg/dL (13.9 mmol/L).
Managing DKA safely focuses on resolving hyperglycemia and acidosis while preventing treatment-induced complications. Hourly blood glucose checks prevent profound hypoglycemia. Adding dextrose to the IV fluids when glucose reaches 250 mg/dL prevents rapid osmotic shifts that can lead to fatal cerebral edema. Continuous ECG monitoring is critical because insulin drives potassium into cells, and the resulting hypokalemia can trigger life-threatening cardiac arrhythmias.

Step-by-Step Solution

1
Analyze the client's current condition and prescribed therapy.
The client is in a state of DKA and is receiving a continuous infusion of IV regular insulin, which rapidly lowers both glucose and potassium levels.
Understanding the physiological impact of the primary treatment is necessary to anticipate and prevent iatrogenic complications.
2
Interpret the provided arterial blood gas (ABG) results.
The values (pH 7.31, PaCO2 32 mm Hg, HCO3 15 mEq/L) indicate partially compensated metabolic acidosis. The low PaCO2 is a compensatory mechanism, not a separate primary disorder.
Accurate ABG interpretation ensures the nurse does not inappropriately intervene to stop a necessary compensatory mechanism (like Kussmaul respirations) or administer unneeded, dangerous medications like bicarbonate.
3
Select interventions that actively reduce the risk of expected complications based on the assessment.
Select hourly glucose checks, ECG monitoring for hypokalemia-induced dysrhythmias, and the addition of dextrose to prevent cerebral edema. Reject actions that worsen the condition, such as flat positioning or inappropriate medication administration.
The nurse's core responsibility in high-acuity scenarios is to implement safety protocols that mitigate the known risks of the disease process and its medical management.

Key Concept

Risk reduction in Diabetic Ketoacidosis (DKA) management requires vigilant monitoring for hypokalemia and hypoglycemia, preventing cerebral edema with timely dextrose administration, and recognizing appropriate physiological compensation.
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Reduction of Risk Potential

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