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Difficulty: Very hardPhysiological Adaptation

A nurse is caring for a client admitted with severe diabetic ketoacidosis (DKA). The client is receiving a continuous intravenous regular insulin infusion and 0.9% sodium chloride. The nurse observes that the client's deep, rapid breathing has transitioned to shallow, weak respirations over the last 3030 minutes, and the client is now profoundly lethargic and difficult to arouse.

Recent laboratory results:
- Blood glucose: 230230 mg/dL (12.812.8 mmol/L)
- Serum potassium: 2.72.7 mEq/L (2.72.7 mmol/L)
- Arterial Blood Gas (room air): pH 7.207.20, PaCO 2_2 4949 mm Hg, HCO 3−_3^- 1111 mEq/L, PaO 2_2 8282 mm Hg

Which of the following is the priority nursing action?

  1. Discontinue the regular insulin infusion and activate the rapid response team.Answer
  2. B
    Change the intravenous fluid to 5% dextrose in 0.45% sodium chloride.
  3. C
    Prepare to administer a prescribed intravenous sodium bicarbonate infusion.
  4. D
    Increase the rate of the 0.9% sodium chloride infusion to maximize tissue perfusion.

Answer

Discontinue the regular insulin infusion and activate the rapid response team.
The client is exhibiting signs of impending respiratory failure and severe hypokalemia. In DKA, the expected respiratory compensation for metabolic acidosis is hyperventilation (Kussmaul respirations), which lowers PaCO2. A PaCO2 of 49 mm Hg in this context indicates respiratory muscle fatigue, directly secondary to the profound hypokalemia (2.7 mEq/L). Because insulin actively shifts potassium into the intracellular space, continuing the insulin infusion will fatally worsen the hypokalemia. The nurse must immediately stop the insulin infusion to prevent cardiac and respiratory arrest, and activate the rapid response team to secure the airway and initiate emergency potassium replacement.

Step-by-Step Solution

1
Analyze the arterial blood gas (ABG) and respiratory assessment.
The client has a severe metabolic acidosis (HCO3- 11 mEq/L, pH 7.20) but an elevated PaCO2 (49 mm Hg), indicating a failure of the expected respiratory compensation (loss of Kussmaul respirations).
Identifying the mixed acid-base disorder reveals that the client is experiencing respiratory muscle fatigue and impending respiratory arrest.
2
Evaluate the serum electrolytes in the context of the prescribed treatment.
The serum potassium is critically low at 2.7 mEq/L. The continuous insulin infusion actively drives potassium into the intracellular space.
Severe hypokalemia causes profound muscle weakness, including paralysis of the diaphragm and intercostal muscles, which directly explains the shallow respirations and rising PaCO2.
3
Prioritize interventions based on the ABCs (Airway, Breathing, Circulation).
The most immediate threats to life are respiratory failure and fatal arrhythmias from hypokalemia. The nurse must stop the insulin to prevent further potassium shifts and call for emergency assistance to secure the airway.
Addressing the critical ABC threat supersedes standard DKA protocol actions, such as adding dextrose to the intravenous fluids.

Key Concept

Prioritization in DKA complications and recognition of hypokalemia-induced respiratory failure.
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Topics

Physiological Adaptation

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