Examkin

Question

Difficulty: Very hardReduction of Risk Potential

A nurse is reviewing the electronic health record of a young adult client admitted with diabetic ketoacidosis. The client has been receiving a continuous regular insulin infusion and 0.9% sodium chloride for the past four hours.

Current clinical data:
- Vital signs: Heart rate 112/min, Blood pressure 108/65 mm Hg, Respiratory rate 22/min
- Cardiac monitor: Sinus tachycardia with frequent premature ventricular contractions
- Capillary blood glucose: 235 mg/dL
- Arterial Blood Gases: pH 7.31, PaCO2 36 mm Hg, HCO3 15 mEq/L
- Basic Metabolic Panel: Sodium 142 mEq/L, Potassium 3.1 mEq/L, Chloride 105 mEq/L

Which of the following is the priority nursing action to reduce the client's risk of a life-threatening complication?

  1. A
    Change the continuous intravenous fluid to 5% dextrose in 0.45% sodium chloride.
  2. B
    Administer intravenous sodium bicarbonate to correct the metabolic acidosis.
  3. Suspend the continuous regular insulin infusion and notify the healthcare provider.Answer
  4. D
    Increase the infusion rate of the 0.9% sodium chloride to treat hypovolemia.

Answer

Suspend the continuous regular insulin infusion and notify the healthcare provider.
The correct action directly addresses the most immediate, life-threatening risk: severe hypokalemia leading to fatal cardiac dysrhythmias. The client's potassium is critically low at 3.1 mEq/L, and they are already exhibiting premature ventricular contractions. Because insulin shifts potassium intracellularly, continuing the insulin infusion will worsen the hypokalemia. Standard DKA protocols require holding the insulin infusion if the potassium level falls below 3.3 mEq/L until aggressive potassium replacement is initiated.

Step-by-Step Solution

1
Analyze the client's current diagnostic and clinical data.
The client has a serum potassium level of 3.1 mEq/L and is experiencing premature ventricular contractions (PVCs) on the cardiac monitor.
Normal serum potassium is 3.5 to 5.0 mEq/L. Levels below 3.3 mEq/L in the setting of diabetic ketoacidosis indicate severe depletion and myocardial irritability.
2
Evaluate the physiological effects of the current medical interventions.
The continuous intravenous insulin infusion drives both glucose and potassium from the intravascular space into the intracellular space.
Continuing the insulin infusion will further lower the serum potassium level, severely exacerbating the hypokalemia.
3
Determine the highest priority intervention to mitigate the immediate threat to life.
The nurse must immediately stop the insulin infusion and contact the healthcare provider to initiate potassium replacement.
According to evidence-based protocols, insulin therapy is contraindicated and must be held when serum potassium falls below 3.3 mEq/L to prevent lethal ventricular arrhythmias.

Key Concept

Diabetic ketoacidosis management requires vigilant monitoring of potassium, and insulin must be held if serum potassium falls below 3.3 mEq/L to prevent lethal dysrhythmias.
Rate this question

Topics

Reduction of Risk Potential

More questions from this topic