A client is admitted to the intensive care unit with diabetic ketoacidosis (DKA). At admis… — NCLEX-RN

A client is admitted to the intensive care unit with diabetic ketoacidosis (DKA). At admission, the client's serum glucose was $720\text{ mg/dL}$ ( $40.0\text{ mmol/L}$ ) and serum potassium was $5.2\text{ mEq/L}$ ( $5.2\text{ mmol/L}$ ). The client was started on a continuous intravenous (IV) regular insulin infusion and fluid resuscitation with $0.9\%$ sodium chloride.

Four hours later, the client's serum glucose is $245\text{ mg/dL}$ ( $13.6\text{ mmol/L}$ ) and serum potassium is $3.7\text{ mEq/L}$ ( $3.7\text{ mmol/L}$ ). The anion gap remains elevated at $18\text{ mEq/L}$ (normal: $8-12\text{ mEq/L}$ ). Which of the following modifications to the client's parenteral therapy should the nurse anticipate next?

Change the continuous IV fluid to include $5\%$ dextrose and add intravenous potassium chloride.Cevap
B
Discontinue the continuous insulin infusion and administer a subcutaneous dose of rapid-acting insulin.
C
Administer intravenous sodium bicarbonate to rapidly correct the elevated anion gap acidosis.
D
Maintain the $0.9\%$ sodium chloride but decrease the IV insulin rate to $1\text{ unit/hr}$ to prevent hypoglycemia.

Cevap

The nurse should anticipate changing the continuous IV fluid to include

5\%

dextrose and adding intravenous potassium chloride.

The correct action is to add

5\%

dextrose to the IV fluids and initiate potassium supplementation. In the treatment of DKA, insulin resolves both hyperglycemia and ketoacidosis. However, blood glucose normalizes much faster than ketones are cleared. When glucose falls below

250\text{ mg/dL}

5\%

dextrose must be added to the IV fluids. This provides a carbohydrate source, preventing hypoglycemia while allowing the nurse to keep the insulin infusion running to close the elevated anion gap. Furthermore, insulin shifts potassium into the cells. With a potassium level of

3.7\text{ mEq/L}

and an active insulin drip, potassium replacement is critical to prevent cardiac dysrhythmias.

Adım Adım Çözüm

Evaluate the current serum glucose trend.

Glucose has dropped from

720\text{ mg/dL}

245\text{ mg/dL}

In DKA management, a glucose level crossing below the

250\text{ mg/dL}

threshold indicates the critical need for dextrose supplementation.

Assess the status of the ketoacidosis.

The anion gap is

18\text{ mEq/L}

, indicating that active ketoacidosis is still present.

An elevated anion gap means the continuous insulin infusion must be maintained to suppress lipolysis and ketone production.

Evaluate the serum potassium trend.

Potassium has dropped from

5.2\text{ mEq/L}

3.7\text{ mEq/L}

Insulin facilitates the intracellular shift of potassium. As the level falls to the lower end of normal, prophylactic IV potassium must be initiated to prevent severe hypokalemia and fatal arrhythmias.

Synthesize the findings to determine the correct therapy adjustment.

Add dextrose to prevent hypoglycemia, continue insulin to close the anion gap, and add potassium to maintain electrolyte balance.

This combination directly addresses all active physiological derangements in this specific transitional phase of DKA.

Anahtar Kavram

In DKA management, when blood glucose falls below

250\text{ mg/dL}

(

13.9\text{ mmol/L}

), IV fluids must be transitioned to include

5\%

dextrose. This allows the continuation of the IV insulin drip, which is essential to close the anion gap and clear ketones, while preventing dangerous hypoglycemia. Concurrently, potassium must be proactively replaced to counteract insulin-driven intracellular shifts.

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