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Difficulty: Very hardPhysiological Adaptation

A nurse is caring for a client newly admitted to the intensive care unit with diabetic ketoacidosis (DKA). The client is lethargic and exhibits deep, rapid respirations. Initial laboratory results reveal a serum blood glucose of 680 mg/dL (37.7 mmol/L), an arterial pH of 7.12, and a serum potassium of 2.7 mEq/L (2.7 mmol/L). In what order should the nurse implement the collaborative interventions? Arrange the actions from first to last.

  1. 1Initiate a rapid intravenous infusion of 0.9% sodium chloride.
  2. 2Administer an intravenous potassium chloride (KCl) piggyback.
  3. 3Begin a continuous intravenous infusion of regular insulin.
  4. 4Assess capillary blood glucose levels every hour.
  5. 5Change the intravenous fluid to include 5% dextrose when glucose reaches 250 mg/dL.

Answer

The correct sequence is: 1) Initiate 0.9% sodium chloride, 2) Administer potassium chloride, 3) Begin regular insulin infusion, 4) Assess blood glucose hourly, 5) Add 5% dextrose to fluids when glucose reaches 250 mg/dL.
In the management of DKA, restoring intravascular volume with isotonic saline is always the first priority to reverse hypovolemic shock. While standard protocols follow fluid resuscitation immediately with a continuous insulin infusion, this client presents with severe hypokalemia (2.7 mEq/L). Insulin actively transports potassium from the extracellular fluid into the cells. Administering insulin prior to correcting this profound hypokalemia would induce a lethal drop in serum potassium, triggering fatal cardiac arrhythmias. Therefore, potassium replacement is the critical second step and must strictly precede the insulin infusion. Once potassium is suitably replaced (>3.3 mEq/L), regular insulin is initiated to halt ketogenesis and lower glucose. Because IV insulin rapidly alters glucose levels, hourly monitoring is mandatory. Finally, when the blood glucose approaches 250 mg/dL, 5% dextrose is added to the maintenance fluids to prevent a rapid fluid shift into the brain (cerebral edema) and to avoid iatrogenic hypoglycemia.

Step-by-Step Solution

1
Analyze the client's laboratory values and clinical presentation.
The client has severe DKA complicated by critical hypokalemia (potassium 2.7 mEq/L).
Identifying critical values alters the standard DKA algorithm, specifically regarding the timing and safety of continuous insulin administration.
2
Identify the most immediate life-threatening physiological deficit.
Profound dehydration and hypovolemia are the most immediate threats to systemic perfusion.
Initial fluid resuscitation with isotonic saline (0.9% NaCl) is required to restore blood pressure and vital organ perfusion before addressing the underlying metabolic derangements.
3
Determine the safety of initiating insulin therapy.
Insulin therapy is currently contraindicated due to the serum potassium level being critically below 3.3 mEq/L.
Insulin facilitates the intracellular shift of both glucose and potassium. Administering insulin to a severely hypokalemic client will rapidly lower intravascular potassium further, risking lethal cardiac arrhythmias. Potassium replacement must occur first.
4
Sequence the remaining metabolic interventions.
Insulin is started after potassium is replaced, followed by strict monitoring and eventually adding dextrose.
Once potassium is safe, insulin corrects the acidosis. Hourly glucose monitoring ensures safe titration. Dextrose is added at 250 mg/dL to prevent cerebral edema from rapid osmolality shifts.

Key Concept

Prioritization of interventions in Diabetic Ketoacidosis (DKA) with concurrent severe hypokalemia.
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Topics

Physiological Adaptation

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