CS 5 - Diabetic Ketoacidosis Flashcards
Mr. D, a 19-year-old premed student, has been brought to the emergency department (ED) by his roommate, who is a medical student and a family friend. Mr. D reports abdominal pain, polyuria, vomiting, and thirst. He appears flushed, and his lips and mucous membranes are dry and cracked. His skin turgor is poor. He has deep, rapid respirations, and there is a fruity odor to his breath. He has type 1 diabetes and “may have skipped a few doses of insulin because of cramming for finals.” He is alert and conversant but is having trouble focusing on the nurse’s questions. Mr. D’s vital signs and blood glucose are as follows:
Blood glucose level (fingerstick) 685 mg/dL (38.1 mmol/L)
Blood pressure 100/60 mm Hg
Heart rate 120 beats/min
Respiratory rate 32 breaths/min
Temperature 100.8°F (38.2°C)
To clarify pertinent data, what questions are appropriate to ask Mr. D? Select all that apply.
- “When did your symptoms start?”
- “How many times have you vomited?”
- “When were you diagnosed with diabetes?”
- “Where does your abdomen hurt?”
- “Did you take any insulin today?”
- “Do you have any allergies?”
Ans: 1, 2, 4, 5, 6 The onset of symptoms and the amount of fluid loss help to
determine acuity. Pain assessment of the abdomen should be performed to
obtain a baseline; his pain is probably associated with diabetic ketoacidosis,
but infection or trauma could also be factors. If Mr. D had insulin today, this
could affect treatment. Information about allergies should be obtained for all
clients regardless of the presenting problem. Knowing when the client was
diagnosed with diabetes does not alter the priority actions at this point.
Focus: Prioritization.
Mr. D, a 19-year-old premed student, has been brought to the emergency department (ED) by his roommate, who is a medical student and a family friend. Mr. D reports abdominal pain, polyuria, vomiting, and thirst. He appears flushed, and his lips and mucous membranes are dry and cracked. His skin turgor is poor. He has deep, rapid respirations, and there is a fruity odor to his breath. He has type 1 diabetes and “may have skipped a few doses of insulin because of cramming for finals.” He is alert and conversant but is having trouble focusing on the nurse’s questions. Mr. D’s vital signs and blood glucose are as follows:
Blood glucose level (fingerstick) 685 mg/dL (38.1 mmol/L)
Blood pressure 100/60 mm Hg
Heart rate 120 beats/min
Respiratory rate 32 breaths/min
Temperature 100.8°F (38.2°C)
The nurse has completed the triage assessment and history taking. Now what
is the priority action?
1. Page the ED health care provider (HCP) to come to triage.
2. Call the client’s parents for permission to treat.
3. Notify the client’s primary HCP.
4. Take the client immediately to a treatment room.
Ans: 4 Mr. D should be taken to a treatment room, where evaluation and
treatment can begin immediately. Paging the ED provider to come to the
triage area is not necessary unless the client becomes unresponsive in the
triage area. Calling the parents is not necessary because Mr. D is old enough
to provide consent for himself. (If Mr. D were under age, the treatment would
not be delayed if the parents were unavailable in an emergency situation.)
Calling the primary HCP is usually done by the ED provider after the
preliminary workup is completed. (Policies for calling primary HCPs vary
among institutions.) Focus: Prioritization.
What is the priority nursing concept to consider in planning the initial emergency interventions for Mr. D? 1. Gas exchange 2. Acid-base imbalance 3. Fluid and electrolyte imbalance 4. Adherence
Ans: 3 Mr. D is severely dehydrated and is at risk for hypovolemic shock and
electrolyte imbalance. Although he is demonstrating Kussmaul respirations,
this breathing pattern is the body’s attempt to compensate for the acidosis.
Acid-base imbalance is usually corrected by administering fluids,
electrolytes, and insulin. Adherence is relevant but can be addressed after Mr.
D’s condition is stabilized. Focus: Prioritization.
Which tasks are appropriate to delegate to an experienced unlicensed
assistive personnel (UAP)? Select all that apply.
1. Measuring and reporting Mr. D’s vital signs every 15 minutes
4812. Checking and reporting Mr. D’s blood glucose level
3. Bagging and labeling Mr. D’s belongings
4. Updating the roommate regarding Mr. D’s status
5. Measuring emesis and cleaning the basin as needed
6. Obtaining an infusion pump from the supply room
Ans: 1, 2, 3, 5, 6 Checking vital signs, bagging up belongings, obtaining
equipment, measuring output, and assisting with hygienic needs (e.g.,
cleaning emesis basin) are within the scope of duties for the UAP. Checking
blood glucose level is accomplished with a fingerstick. UAPs, particularly in
specialty areas such as the ED, will usually receive training to do this task,
but this may vary from state to state and facility to facility. Information
should not be released by the UAP because of confidentiality issues. Release
of information to friends and family varies by facility policies, but typically
the RN would escort the family in to see the client as soon as possible. Focus:
Delegation.
For the initial emergency care of Mr. D, what is the priority collaborative
treatment goal?
1. Correction of hyperglycemia with IV insulin
2. Correction of acid-base imbalance using IV bicarbonate
3. Correction of fluid imbalance with IV fluids
4. Correction of potassium imbalance with IV potassium
Ans: 3 Fluid replacement is the first priority. Furthermore, the fluid dilutes
the glucose levels, which helps to correct osmotic diuresis. The serum
potassium level may not reflect the total body potassium. Hypokalemia is
anticipated because of loss of potassium in the urine; however, potassium
levels are closely monitored, and supplements are given accordingly. Insulin
is given to slowly lower the blood glucose level, but this occurs after
rehydration and evaluation of potassium levels. Bicarbonate is rarely given
unless acidosis becomes life threatening; acidosis usually resolves with fluids,
488electrolytes, and insulin. Focus: Prioritization.
In the initial emergency care for Mr. D, which HCP prescriptions would the
nurse question? Select all that apply.
1. Start a peripheral IV line with a large-bore catheter.
2. Obtain a urine specimen with a small-bore straight catheter.
3. Administer regular insulin subcutaneously.
4. Maintain the client in a semi-Fowler position.
5. Initiate continuous electrocardiographic (ECG) monitoring.
6. Encourage intake of oral fluids as tolerated.
Ans: 2, 3, 6 The nurse should question the insertion of a straight catheter to
obtain a urine specimen for a client who is alert and able to use a urinal or
commode because there is currently an emphasis to reduce catheter-
associated urinary tract infections. (Note to student: The HCP may order an
indwelling catheter for critically ill clients because hourly urinary output
reflects cardiac output and kidney perfusion.) Subcutaneous insulin is not
absorbed fast enough and is inappropriate for emergency situations. (IV
insulin would be appropriate.) The client is likely to be on food and fluid
restrictions until the vomiting resolves. In addition, intra-abdominal
conditions (e.g., appendicitis) should be ruled out before allowing oral fluids.
At least one peripheral IV is needed for fluid replacement during the acute
period. Semi-Fowler position is preferred to reduce the risk for aspiration.
ECG monitoring is appropriate for all critical care clients. In this case,
electrolyte imbalances increase the risk for dysrhythmias. Focus:
Prioritization; Test Taking Tip: If the nurse is questioning the HCP, the plan
of care, or the interventions, the question is asking you to identify the
incorrect options.
What does the nurse anticipate the HCP will order for the initial fluid
replacement?
1. Normal saline (0.9% sodium chloride)
2. Half-strength saline (0.45% sodium chloride)
3. 5% dextrose in water and half-strength saline
4. Normal saline with potassium chloride
Ans: 1 Normal saline (0.9% sodium chloride) is the first fluid used to correct
dehydration in most adults with diabetic ketoacidosis. Half-strength saline
(0.45% sodium chloride) can be used for children and adults at risk for
volume overload. Potassium supplements are added within 1 to 2 hours after
starting insulin. Solutions of 5% dextrose are added to the therapy when the
blood glucose level approaches 250 mg/dL (13.9 mmol/L). Focus:
Prioritization.
The HCP instructs the nurse to give 1 L of IV fluid over the next hour. The
available IV pump delivers fluid in mL/hr and allows three digits for
programming the flow rate. What should the nurse do first?
1. Try to find a pump that will accurately deliver the fluid.
2. Program the IV pump for 1 L/hr and start the infusion.
3. Ask the HCP to revise the rate to accommodate the available equipment.
4. Program the IV pump for 999 mL/hr and start the infusion.
Ans: 4 Many pumps only allow 3 digits for programming flow, so the nurse
knows to use the available IV pump and program the rate to 999 mL/hr. It
would not be possible to change the pump to deliver in L/hr. Focus:
Prioritization.
The arterial blood gas results for Mr. D are: pH 7.25 PaO2 97 mm Hg Paco2 25 mm Hg Bicarbonate 19 mEq/L (19 mmol/L)
Ans: 1 The arterial blood gas results indicate metabolic acidosis. The pH is
low (reference range, 7.35–7.45). Bicarbonate level is low (reference range, 21–
28 mEq/L [21–28 mmol/L]). Pa O 2 is normal because gas exchange is not
impaired in metabolic acidosis. Paco 2 is decreased because the deep and rapid
Kussmaul respirations are the body’s attempt to lower the pH by blowing off
carbon dioxide. Focus: Prioritization.
The nurse is reviewing the potassium values that were obtained when Mr. D
first arrived in the ED. Which serum potassium level is most concerning?
1. 3.5 mEq/L (3.5 mmol/L)
2. 2 mEq/L (2 mmol/L)
3. 5.8 mEq/L (5.8 mmol/L)
4. 6 mEq/L (6 mmol/L)
Ans: 2 Initially in clients with diabetic ketoacidosis, the serum potassium
level is expected to be within normal limits or elevated; regardless of the
laboratory value, there is an overall potassium deficit. After insulin therapy,
hypokalemia is expected as the potassium shifts back into the cells; therefore,
if the potassium level is initially low, it will be even lower after therapy.
Focus: Prioritization; Test Taking Tip: Potassium imbalances can cause lethal
cardiac dysthymias. It is likely that the NCLEX® Examination will include
questions about potassium levels. It is worthwhile to memorize the reference
489range.
An insulin infusion is ordered for Mr. D to begin at 0.1 units/kg/hr. Mr. D
weighs 155 lb. The pharmacy delivers a premixed bag of 100 units of regular
insulin in 100 mL of normal saline. Nurse A has calculated the infusion pump
setting as 10 mL/hr. What will the charge nurse do next?
1. Tell Nurse A to obtain a pump and start the infusion as calculated.
2. Advise Nurse A to recalculate the infusion rate.
3. Call the HCP and ask for the exact pump setting to be clarified.
4. Allow Nurse A to administer the infusion using her own judgment.
Ans: 2 Her calculations are incorrect. The pump should be set at 7 mL/hr.
155/2.2 = 70.4 kg; round to 70 kg
70 kg/x units : 1 kg/0.1 units = 7 units
100 units/100 mL = 1 unit/1 mL : 7 units/x mL = 7 mL
Calling the HCP is inappropriate; the nurse is responsible for calculating the
pump settings. Insulin is a high-alert drug, and calculations must always be
double-checked. When discrepancies are discovered, the source of the error
must be determined and corrected. Focus: Prioritization, Supervision; Test
Taking Tip: When weight is given in pounds and medications or fluids are
prescribed per kilogram, pounds must first be converted to kilograms.
Mr. D says to the nurse, “Please don’t call my mother. If she knows I’m in
the hospital, she’ll make me quit school and move back home. I know I
messed up, but I really don’t want to move back in with my parents.” What is
the best therapeutic communication response?
1. “None of the staff will say anything, but you should tell her yourself.”
2. “Your mom loves you, and she is just concerned about your well-being.”
3. “It sounds like you want to be independent and responsible for yourself.”
4. “You are an adult, and you have a right to make your own decisions.”
Ans: 3 Acknowledging and reflecting underlying feelings is therapeutic.
Options 1 and 4 give unsolicited advice, and option 2 is a platitude that is not
supported by firsthand knowledge of the mother–son relationship. Focus:
Prioritization; Test Taking Tip: To provide a therapeutic answer, first
determine what the client is trying to express; then determine the need. In
this case, the nurse selects reflection to help Mr. D to expand on his emotional
concerns.
The nurse overhears the UAP talking to someone on the phone. The UAP
says, “Yes, Mr. D is doing much better than when he first got here. I will tell
him that you called, and I will give him your message.” What will the nurse
do first?
1. Ask the UAP about the phone conversation that was just overheard.
2. Remind the UAP that release of information is outside her scope of
practice.
3. Report the UAP to the nurse manager for client privacy violation.
4. Give positive feedback for trying to help the client and the caller.
Ans: 1 First, the situation should be assessed to determine if a privacy
violation has occurred. Client information should be released only to facilitate
continuity of care (e.g., in a shift report) and only to those who are directly
involved in the care. If Health Insurance Portability and Accountability Act
(HIPAA) rules were violated, the incident would be reported to the nurse
manager for potential complaints related to the UAP’s actions and so that the
UAP could receive the proper remediation. Giving positive feedback for
sincere efforts to assist clients and families is appropriate, but guidelines
must be recognized and followed. Focus: Supervision.
The ED nurse is reviewing the intensive care unit (ICU) admission orders.
There is a prescription for an IV potassium infusion. Related specifically to
the potassium infusion, which information would the ICU nurse be most interested in knowing?
1. Mental status and cognition have improved with therapy.
2. Urinary output is 60 mL/hr, and urine is a clear yellow color.
3. Admitting blood pressure (BP) was 100/60 mm Hg; last BP is 125/76 mm
Hg.
4. There are two existing peripheral IV lines, and both flush easily.
Ans: 2 Before potassium is administered, it is important to know that the
kidneys are functioning. The other information is important but has less
relevance to the potassium infusion. Focus: Prioritization.
he ED nurse is preparing the SBAR (situation, background, assessment,
recommendation) report before the ICU transfer. Which detail would be most
important to include as background to ensure that Mr. D’s right to privacy is
maintained?
1. Client is a premed student who was studying for finals, and this interfered
with his normal routine.
2. Roommate is a medical student and a family friend, and he brought Mr. D
to the ED.
3. Client has not informed family that he is in the hospital, and he is reluctant
to allow notification.
4. Client arrived alert and conversant, but he initially he had trouble focusing
on questions.
. Ans: 3 The nursing staff is likely to encourage the client to inform his family,
but the ICU staff should be aware that he is resistant to notifying his family.
(Note to student: Policies vary greatly, but some facilities do not allow staff to
confirm or deny the admission or discharge of clients. In such cases, the client
may be asked to provide a list of people that can visit or phone in.) Focus:
Prioritization.
