A known diabetic client comes to the emergency department with a random blood sugar of 400 mg/dL, Kussmaul respirations, and a serum potassium of 5.8 mEq/L. Which intervention should the nurse carry out first?

1. A

   Start an IV infusion of 0.9 percent sodium chloride

2. B

   Add potassium chloride to the IV fluids

3. C

   Start an IV infusion of regular insulin

4. D

   Give IV sodium bicarbonate

Appeared in: NORCET-11 Mains

Explanation

• The primary problem in the initial phase of DKA is profound dehydration due to osmotic diuresis caused by hyperglycemia.
• The first priority in management is to restore intravascular volume and tissue perfusion by administering isotonic intravenous fluids, such as 0.9% sodium chloride.
• Fluid resuscitation helps stabilize the patient's circulatory status, improves renal function to allow for excretion of glucose and ketones, and must precede insulin administration to prevent complications.
• Starting with fluid replacement addresses the most immediate life-threatening condition, which is circulatory collapse from severe dehydration.

Why Other Options Were Wrong

• Option B: The patient's serum potassium is already elevated (5.8 mEq/L). Administering more potassium would be dangerous and could cause fatal cardiac arrhythmias.
• Close distractor alert - Option C: Administering insulin before correcting dehydration can worsen the fluid deficit by shifting water into cells. More critically, it drives potassium into cells, which can cause a rapid and severe drop in serum potassium, leading to life-threatening hypokalemia.
• Option D: Sodium bicarbonate is not a routine first-line treatment for DKA. The acidosis is best corrected by stopping ketone production with insulin. Bicarbonate therapy is associated with risks like hypokalemia and paradoxical CNS acidosis.

Related Visual

Clinical Relevance

• Nursing practice connection: Prioritize focused assessment, early escalation, and real-time monitoring when managing Prioritization of nursing interventions in Diabetic Ketoacidosis (DKA) in acute care settings.
• In managing DKA, the sequence of interventions is critical for patient safety. Incorrectly prioritizing insulin before fluids can lead to severe hypokalemia and cardiac arrest, a preventable but fatal complication.
• Nurses must recognize that the initial high potassium level in DKA is a 'pseudo-hyperkalemia' due to acidosis shifting potassium out of cells. The total body potassium is actually depleted, and levels will fall rapidly with treatment.
• What if? If the patient's initial potassium was 3.0 mEq/L (hypokalemic), the priority would still be to start fluids, but insulin would be HELD. Potassium replacement would need to begin immediately, and insulin would only be started once the potassium level was corrected to a safe level (greater than 3.3 mEq/L).

How to Approach the Question

• First, identify the clinical syndrome. The combination of high blood sugar, Kussmaul respirations (indicating acidosis), and a history of diabetes points directly to Diabetic Ketoacidosis (DKA).
• Next, apply the principles of emergency management, focusing on Airway, Breathing, and Circulation (ABCs). DKA causes severe dehydration, which is a critical 'Circulation' problem.
• Evaluate the options based on the pathophysiology of DKA. The primary issue is volume depletion. Therefore, fluid replacement is the most immediate need.
• Consider the risks of each intervention. Giving insulin first risks dangerous hypokalemia. Giving potassium now risks fatal hyperkalemia. Giving bicarbonate is not indicated for most cases. This leaves fluid administration as the safest and most logical first step.

Concept Tested & Keywords

• Concept Tested: Prioritization of nursing interventions in Diabetic Ketoacidosis (DKA).
• Stem keywords: diabetic client, random blood sugar of 400 mg/dL, Kussmaul respirations, serum potassium of 5.8 mEq/L
• Lead-in keywords: first
• Clinical cues: The combination of hyperglycemia, Kussmaul respirations, and hyperkalemia in a diabetic patient is a classic presentation of DKA, which is a medical emergency.

Question ID

QGjp9_-zmT9D7WnmfT9ljd

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Reference Book

E6 Medicine Harrison 22e Part 2 p. 1122-1124

E6 Ghai Essential Pediatrics(pp 26-904 of 913) p. 568-570

E6 Nelson Textbook of Pediatrics(2024) — Volume 2 p. 1332-1334