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Difficulty: Very hardPhysiological Adaptation

A registered nurse is managing the care of a young adult diagnosed with diabetic ketoacidosis. The individual has been receiving a continuous intravenous drip of regular insulin alongside isotonic saline for several hours. A recent metabolic panel and arterial blood gas analysis show a pH of 7.26, PaCO2 of 28 mm Hg, bicarbonate of 14 mEq/L, and a serum potassium level of 3.2 mEq/L. Electrocardiogram monitoring reveals flattened T waves and emerging U waves. Current hemodynamics demonstrate a systolic pressure of 108 mm Hg, diastolic of 70 mm Hg, and a pulse of 110 beats per minute. Which of the following clinical interventions should the nurse prioritize?

  1. A
    Administer a prescribed intravenous sodium bicarbonate push to rapidly correct the severe metabolic acidosis.
  2. B
    Accelerate the isotonic saline infusion to counteract early signs of circulatory shock.
  3. Suspend the continuous insulin infusion and initiate prescribed intravenous potassium replacement.Answer
  4. D
    Apply a partial rebreather mask to increase carbon dioxide retention and treat the respiratory alkalosis.

Answer

The correct intervention is to immediately suspend the continuous insulin infusion and initiate prescribed intravenous potassium replacement.
The individual is experiencing profound hypokalemia, a highly dangerous complication of diabetic ketoacidosis treatment. Regular insulin drives potassium into the intracellular space, rapidly depleting serum levels. When serum potassium falls below 3.3 mEq/L, standard protocols dictate immediately suspending the insulin infusion to prevent fatal cardiac dysrhythmias—as evidenced by the flattened T waves and emerging U waves—and initiating potassium replacement. Continuing insulin would exacerbate the life-threatening hypokalemia.

Step-by-Step Solution

1
Analyze the arterial blood gas (ABG) and metabolic panel results.
The ABGs reveal a partially compensated metabolic acidosis, but the critical and immediately life-threatening finding is the serum potassium level of 3.2 mEq/L.
Identifying the most life-threatening physiological abnormality is the first step in clinical prioritization.
2
Correlate laboratory findings with the clinical presentation and electrocardiogram (ECG).
The flattened T waves and emerging U waves confirm clinically significant and dangerous hypokalemia.
Potassium plays a vital role in cardiac action potentials, and uncorrected hypokalemia can quickly progress to lethal ventricular dysrhythmias.
3
Evaluate the impact of current pharmacological therapy on the client's physiological status.
The continuous insulin infusion is actively driving the remaining extracellular potassium into the cells, exacerbating the hypokalemia.
Understanding the systemic physiological mechanisms of action of insulin is required to anticipate its adverse effects.
4
Determine the immediate priority intervention based on established treatment guidelines.
The nurse must immediately hold the insulin infusion and prepare to administer intravenous potassium.
Standard diabetic ketoacidosis protocols mandate holding insulin therapy when serum potassium falls below 3.3 mEq/L to prevent cardiac arrest.

Key Concept

Management of life-threatening hypokalemia as a physiological complication of insulin therapy in diabetic ketoacidosis.
Estimated Time:2m 0s
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Topics

Physiological Adaptation

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