A 22-year-old client with type 1 diabetes who uses an insulin pump is admitted to the medical unit with nausea. At 0700, capillary glucose was 318 mg/dL and the client gave a correction bolus through the pump. At 0900, glucose is 324 mg/dL, capillary beta-hydroxybutyrate is 1.6 mmol/L, and the client has vomited once. The infusion set was inserted 3 days ago, the tubing has no visible air, and the pump shows no occlusion alarm. Which actions should the nurse take? Select all that apply.

Quick answer
Options 5, 4, and 6: inject the correction, change the set and site, and recheck glucose and ketones.

Why this is correct
A correction bolus normally lowers glucose within 2 hours. Here the value rose from 318 to 324 mg/dL and beta-hydroxybutyrate is 1.6 mmol/L, so the client is developing ketosis. Occlusion alarms detect only complete blockage; a partly dislodged or kinked cannula under the skin can deliver little insulin with no alarm. The safe response is to bypass the pump with an injection, replace the set at a new site, and recheck glucose and ketones about every 2 hours to confirm the trend reverses.

Easy analogy or mental picture
If a garden hose is not watering the plant, you do not turn the tap up; you use a watering can now and replace the hose.

Memory hook
No drop in 2 hours + ketones = needle, not pump: inject, change, recheck.

NCLEX decision rule
When an insulin pump correction fails and ketones are present, treat the pump route as unreliable until proven otherwise; never remove basal insulin in type 1 diabetes.

Why the other choices are wrong
Second pump bolus (option 1): tempting because correction boluses are the usual response to high glucose, but it uses the same failed delivery route. Suspending the pump (option 2): tempting because the client is nauseated and vomiting, but a pump supplies the only basal insulin, so stopping it speeds ketoacidosis. Higher temporary basal at the current site (option 3): temporary basal increases are a real sick-day tool, but they cannot work through a set that is not delivering insulin.