A 24-year-old client with type 1 diabetes is admitted with diabetic ketoacidosis after missing insulin for 2 days. The first liter of 0.9% sodium chloride is infusing. Laboratory results: glucose 480 mg/dL, pH 7.12, bicarbonate 10 mEq/L, anion gap 26, potassium 3.1 mEq/L, sodium 131 mEq/L. The provider has entered the hospital DKA order set, which includes a continuous IV regular insulin infusion and IV potassium chloride per protocol. Which actions should the nurse take? Select all that apply.

Quick answer
Replace potassium first, recheck it before insulin, and keep cardiac monitoring.

Why this is correct
The discriminating detail is the potassium of 3.1 mEq/L. Although total-body potassium is depleted in DKA, the order set's insulin infusion would shift the remaining potassium into cells; current consensus holds insulin until potassium is at least 3.5 mEq/L while giving fluids and potassium. The nurse therefore sequences the order set rather than starting everything at once, rechecks potassium, and monitors the ECG for hypokalemic changes.

Easy analogy or mental picture
Insulin is a doorman that ushers potassium into the cells; if the hallway (serum) is already nearly empty, open the door and the heart is left with nothing.

Memory hook
K below 3.5: potassium before insulin.

NCLEX decision rule
In DKA, check potassium before insulin: fluids first, potassium replacement if low, insulin only once potassium is adequate.

Why the other choices are wrong
An insulin bolus is still taught in many courses and appears in older protocols, but it is optional at best and here would worsen hypokalemia. Bicarbonate is tempting because the pH is well below normal, yet guidelines limit it to pH below 7.0 because it can worsen hypokalemia and has no outcome benefit at 7.12. Sodium 131 mEq/L looks like true hyponatremia, but correcting for a glucose of 480 mg/dL gives about 137 mEq/L, so hypertonic saline would be harmful.