A patient with diabetes mellitus has a blood glucose level of 644 mg/dl. The management of this patient would include the following EXCEPT?

1. A

   IV Fluids

2. B

   IV Insulin Infusion

3. C

   Correction of metabolic acidosis

4. D

   IV Corticosteroid

Appeared in: RML 2023

Explanation

• IV Corticosteroids are contraindicated in the management of a hyperglycemic crisis.
• Corticosteroids are counter-regulatory hormones (like cortisol) that increase hepatic glucose production (gluconeogenesis) and cause insulin resistance.
• Administering corticosteroids would further elevate the already dangerously high blood glucose level, exacerbating the crisis and opposing the goal of treatment.

Why Other Options Were Wrong

• Option A: IV fluids are the first-line and most critical intervention for hyperglycemic crises.
• Option B: IV insulin infusion is essential for managing hyperglycemic crises.
• Option C: Correction of metabolic acidosis is a primary goal of DKA management.

Related Visual

Clinical Relevance

• Nursing practice connection: Use the key finding related to Management of Hyperglycemic Emergencies to guide bedside assessment, documentation, and the next nursing action.
• Recognizing and rapidly initiating treatment for hyperglycemic crises (DKA/HHS) is a critical nursing skill, as these are life-threatening emergencies.
• Nurses must be vigilant about medications that can increase blood glucose, such as corticosteroids, and question any orders that seem inappropriate for a patient in a hyperglycemic state.
• What if? If the patient's initial potassium level was low (e.g., below 3.3 mEq/L), the nurse should anticipate holding the insulin infusion and repleting potassium first. Insulin drives potassium into cells, and starting it with pre-existing hypokalemia could cause fatal cardiac arrhythmias.

How to Approach the Question

• First, identify the clinical situation from the data provided. A blood glucose of 644 mg/dl in a diabetic patient indicates a hyperglycemic crisis (DKA or HHS).
• Next, analyze the question's keyword: 'EXCEPT'. This signals that you must find the option that is NOT a standard or appropriate treatment.
• Evaluate each option against the standard protocol for managing DKA/HHS.
• Recall the three main pillars of treatment: Fluids, Insulin, and Electrolyte management.
• IV Fluids, IV Insulin, and Correction of acidosis (a result of insulin therapy) are all standard components of care.
• Consider the pharmacological action of corticosteroids. They are known to raise blood glucose. Therefore, administering them would be contraindicated and is the correct answer for an 'EXCEPT' question.

Concept Tested & Keywords

• Concept Tested: Management of Hyperglycemic Emergencies
• Stem keywords: diabetes mellitus, blood glucose level of 644 mg/dl, management
• Lead-in keywords: EXCEPT
• Clinical cues: Blood glucose of 644 mg/dl indicates a severe hyperglycemic crisis (DKA or HHS).
• Negative lead-in flag: Question asks for the management to be EXCLUDED.

Question ID

QjAGujlyy4dQdVZ-SDeNgt

Copy ID

Reference Book

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

E6 Medicine Harrison 22e Part 2 p. 1123-1125