A patient with type 1 diabetes mellitus presents with a blood glucose level >500 mg/dL. With DKA condition showing Acetonic breath and kussumul respiration. What is the most appropriate initial treatment?

1. A

   Administer insulin

2. B

   Provide IV fluid isotonic

3. C

   Administer Sodium bicarbonate

4. D

   Provide Potassium

Appeared in: NORCET 10 Prelims-2026

Explanation

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• The primary pathophysiological problem to address initially in DKA is severe dehydration caused by osmotic diuresis from hyperglycemia.
• Restoring intravascular volume with isotonic IV fluids is the top priority to prevent circulatory collapse, stabilize hemodynamic status, and improve renal perfusion.
• Fluid replacement alone begins to lower blood glucose levels by dilution and improved urinary excretion.
• All standard DKA management guidelines state that fluid resuscitation is the first and most critical step before initiating insulin therapy.

Why Other Options Were Wrong

• Option A: Administering insulin before correcting dehydration is dangerous. It causes a rapid shift of fluid from the intravascular space into cells as glucose moves intracellularly, which can worsen hypotension and lead to circulatory collapse.
• Option C: Sodium bicarbonate is not routinely used and can be harmful. It can cause paradoxical central nervous system acidosis, hypokalemia, and fluid overload.
• Option D: Although patients with DKA have a total body potassium deficit, their initial serum potassium can be normal or even high due to the extracellular shift caused by acidosis. Giving potassium initially could lead to dangerous hyperkalemia.

Related Visual

Clinical Relevance

• Nursing practice connection: Use the key finding related to Prioritization of interventions in the management of Diabetic Ketoacidosis (DKA) to guide bedside assessment, documentation, and the next nursing action.
• A nurse's primary role in initial DKA management is to establish IV access and rapidly administer the prescribed isotonic fluids. This is a critical life-saving intervention.
• Nurses must meticulously monitor vital signs (especially blood pressure), urine output, and neurological status to assess the patient's response to fluid resuscitation.
• What if? If the patient had a known history of congestive heart failure (CHF), the initial fluid resuscitation would be more cautious. The nurse would administer fluids at a slower rate and monitor closely for signs of fluid overload, such as respiratory distress, crackles in the lungs, or jugular venous distention. A central venous line might be placed for accurate fluid status monitoring.

How to Approach the Question

• First, identify the patient's condition from the signs and symptoms: high blood glucose, acetonic breath, and Kussmaul respirations clearly point to Diabetic Ketoacidosis (DKA).
• Recognize that this is a priority-setting question asking for the 'most appropriate initial' treatment.
• Apply the principles of emergency management, often following the ABCs (Airway, Breathing, Circulation). In DKA, the most immediate threat to 'Circulation' is hypovolemic shock from dehydration.
• Evaluate the options based on this priority. Fluid replacement directly addresses the circulatory collapse.
• Consider the consequences of choosing other options first. Giving insulin before fluids worsens the circulatory problem. Bicarbonate and potassium are not initial priorities and can be harmful if given at the wrong time.
• Therefore, select the intervention that stabilizes the most immediate life-threatening problem: IV fluid administration.

Concept Tested & Keywords

• Concept Tested: Prioritization of interventions in the management of Diabetic Ketoacidosis (DKA).
• Stem keywords: type 1 diabetes mellitus, DKA, blood glucose >500 mg/dL, Acetonic breath, Kussmaul respiration, initial treatment
• Lead-in keywords: most appropriate initial
• Clinical cues: Blood glucose >500 mg/dL indicates severe hyperglycemia.
• Clinical cues: Acetonic breath and Kussmaul respiration are classic signs of metabolic acidosis from ketosis.

Question ID

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Reference Book

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

E6 Medicine Davidson Principles Practice 24e p. 757-759

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