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Question 1 of 1
1. Question
The nurse is caring for a client admitted to the emergency department with diabetic ketoacidosis (DKA). In the acute phase, the nurse plans for which priority intervention?
Correct
Option 4 is the correct Answer.
Rationale: Lack of insulin (absolute or relative) is the primary cause of DKA. Treatment consists of insulin administration (short- or rapid-acting), intravenous fluid administration (normal saline initially, not 5% dextrose), and potassium replacement, followed by correcting acidosis. Cardiac monitoring is important due to alterations in potassium levels associated with DKA and its treatment, but applying an electrocardiogram monitor is not the priority action.
Test-Taking Strategy: Focus on the client’s diagnosis. Note the strategic word, priority. Remember that in DKA, the initial treatment is short- or rapid-acting insulin. Normal saline is administered initially; therefore, option 2 is incorrect. Options 1 and 3 may be components of the treatment plan but are not the priority.
Incorrect
Option 4 is the correct Answer.
Rationale: Lack of insulin (absolute or relative) is the primary cause of DKA. Treatment consists of insulin administration (short- or rapid-acting), intravenous fluid administration (normal saline initially, not 5% dextrose), and potassium replacement, followed by correcting acidosis. Cardiac monitoring is important due to alterations in potassium levels associated with DKA and its treatment, but applying an electrocardiogram monitor is not the priority action.
Test-Taking Strategy: Focus on the client’s diagnosis. Note the strategic word, priority. Remember that in DKA, the initial treatment is short- or rapid-acting insulin. Normal saline is administered initially; therefore, option 2 is incorrect. Options 1 and 3 may be components of the treatment plan but are not the priority.
Diabetic ketoacidosis (DKA)
Diabetic ketoacidosis is a life threatening complication of type 1 diabetes mellitus that develops when a severe insulin deficiency occurs. The main clinical manifestations include hyperglycemia, dehydration, ketosis, and acidosis.
Nursing Interventions
Restore circulating blood volume and protect against cerebral, coronary, and renal hypoperfusion.
Treat dehydration with rapid IV infusions of 0.9% or 0.45% NS as prescribed; dextrose is added to IV fluids when the blood glucose level reaches 250 to 300 mg/dL (14 to 17 mmol/L). Too rapid administration of IV fluids; use of the incorrect types of IV fluids, particularly hypotonic solutions; and correcting the blood glucose level too rapidly can lead to cerebral edema.
Treat hyperglycemia with insulin administered intravenously as prescribed.
Correct electrolyte imbalances (potassium level may be elevated as a result of dehydration and acidosis).
Monitor potassium level closely, because when the client receives treatment for the dehydration and acidosis, the serum potassium level will decrease and potassium replacement may be required.
Cardiac monitoring should be in place for the client with DKA due to risks associated with abnormal serum potassium levels.
