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Difficulty: MediumPhysiological Adaptation

A client is admitted to the emergency department with a diagnosis of severe diabetic ketoacidosis (DKA). The client is lethargic, has a respiratory rate of 3232 breaths/minute with deep, rapid breathing, and a blood glucose level of 680680 mg/dL (37.737.7 mmol/L). Arrange the following nursing actions in the correct priority order of implementation.

  1. 1Assess the client's airway patency and respiratory status.
  2. 2Administer rapid intravenous fluid resuscitation with 0.9%0.9\% sodium chloride.
  3. 3Verify the client's initial serum potassium level.
  4. 4Initiate a continuous intravenous infusion of regular insulin.
  5. 5Add 5%5\% dextrose to the maintenance intravenous fluids.

Answer

The correct sequence is: 1. Assess airway and respiratory status, 2. Administer rapid intravenous fluid resuscitation with 0.9% sodium chloride, 3. Verify the client's initial serum potassium level, 4. Initiate a continuous intravenous infusion of regular insulin, 5. Add 5% dextrose to the maintenance intravenous fluids.
The correct sequence of actions for managing a client with Diabetic Ketoacidosis (DKA) follows the ABCs and standard emergency protocols. First, the nurse must assess the airway and respiratory status, as the client is lethargic and experiencing Kussmaul respirations. Second, reversing severe dehydration with isotonic fluids (0.9% sodium chloride) is the most critical physiological priority to prevent hypovolemic shock. Third, the nurse must verify the serum potassium level; insulin drives potassium into the cells, so administering insulin to a hypokalemic patient can cause lethal cardiac dysrhythmias. Fourth, a continuous regular insulin infusion is initiated to resolve the ketoacidosis. Finally, when the blood glucose approaches 250 mg/dL, 5% dextrose must be added to the intravenous fluids to prevent hypoglycemia and cerebral edema.

Step-by-Step Solution

1
Assess the client's airway patency and respiratory status.
Airway is secured and Kussmaul respirations are closely monitored.
According to the ABC (Airway, Breathing, Circulation) prioritization framework, securing the airway is always the initial action for a compromised or lethargic client.
2
Administer rapid intravenous fluid resuscitation with 0.9% sodium chloride.
Intravascular volume is expanded and tissue perfusion is restored.
Severe dehydration is the most immediate life-threatening metabolic issue in DKA; isotonic normal saline rapidly restores circulating volume.
3
Verify the client's initial serum potassium level.
Baseline potassium is confirmed to prevent severe hypokalemia.
Insulin shifts potassium into the intracellular space. The nurse must ensure the potassium level is adequate (typically >3.3 mEq/L) before starting insulin to avoid fatal dysrhythmias.
4
Initiate a continuous intravenous infusion of regular insulin.
Blood glucose levels begin to steadily decrease and ketone production stops.
Regular insulin acts to reverse the underlying ketoacidosis and cellular starvation.
5
Add 5% dextrose to the maintenance intravenous fluids.
Hypoglycemia and potential cerebral edema are prevented.
Once the blood glucose level drops to approximately 250 mg/dL, dextrose must be added to prevent a rapid hypoglycemic shift while insulin continues to be administered to clear ketones.

Key Concept

Prioritization and acute management of Diabetic Ketoacidosis (DKA)
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Topics

Physiological Adaptation

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