A nurse in the intensive care unit is caring for a client with type 1 diabetes mellitus who presents with a blood glucose level of 480 mg/dL, large ketones in the urine, and an arterial blood pH of 7.25. To prevent life-threatening complications, which intervention should the nurse prioritize?

In DKA, the priority intervention is administering IV regular insulin to stop ketone production and reduce blood glucose levels. This addresses the underlying pathophysiology of DKA.

Core Nursing Explanation Key Concept Analysis: This question assesses the priority nursing intervention for a patient in Diabetic Ketoacidosis (DKA). DKA is a life-threatening complication of Type 1 Diabetes Mellitus (T1DM) characterized by hyperglycemia, ketosis, and metabolic acidosis. The core pathophysiology involves an absolute insulin deficiency, leading to uncontrolled gluconeogenesis, lipolysis, and ketone production. The priority is to reverse the underlying metabolic derangement by administering insulin.

Answer Rationale: Key Point! The priority is Administer prescribed IV regular insulin as ordered. Insulin is the cornerstone of DKA treatment because it directly inhibits lipolysis and ketogenesis, halts the production of new ketones, and facilitates glucose uptake by cells. This action addresses the root cause of the acidosis and hyperglycemia. All other interventions are supportive but secondary to initiating insulin therapy.

Distractor Analysis:
Watch out for confusion! Option ②, encouraging oral fluids, is incorrect. While fluid resuscitation is critical in DKA, it is almost always administered intravenously (IV) in the initial phase, especially in a critically ill patient in the ICU. Oral intake may be insufficient and is not the priority over starting insulin.
Watch out for confusion! Option ③, administering sodium bicarbonate, is a common trap. Bicarbonate therapy is controversial and typically reserved for severe acidosis (pH < 7.0) or life-threatening hyperkalemia. It is not a first-line treatment and can cause paradoxical central nervous system acidosis and other complications.
Watch out for confusion! Option ④, monitoring blood glucose every 4 hours, is inadequate. In DKA, blood glucose must be monitored much more frequently—typically every hour—to guide insulin titration and prevent hypoglycemia. This monitoring is essential but follows the action of initiating the insulin drip.

Related Concepts: The management of DKA follows the "FIx" mnemonic: Fluids, Insulin, and examination of electrolytes (especially potassium). Fluids restore intravascular volume and correct dehydration. Insulin corrects hyperglycemia and ketosis. Potassium must be monitored closely, as insulin administration drives potassium into cells, potentially causing severe hypokalemia.

Nursing Clinical Practice Guide Clinical Scenario: You are the ICU nurse for Mr. Johnson, a 22-year-old with T1DM, admitted with nausea, vomiting, and altered mental status. His initial labs show: Blood glucose 480 mg/dL, positive serum and urine ketones, ABG pH 7.25, and potassium 5.2 mEq/L.

Nursing Intervention Strategy: 1. Assessment & Priority Setting: Perform a rapid ABC (Airway, Breathing, Circulation) assessment. Assess for Kussmaul respirations (deep, rapid breathing), signs of dehydration (poor skin turgor, dry mucous membranes), and level of consciousness. 2. Immediate Action: Initiate two large-bore IV lines. Key Point! Start IV fluid resuscitation with 0.9% Normal Saline (NS) as ordered, typically 1-2 liters in the first 1-2 hours, followed by a switch to 0.45% NS. Concurrently, prepare and initiate the IV regular insulin infusion via an infusion pump, as it is the definitive treatment. 3. Monitoring: Monitor blood glucose hourly. Monitor serum electrolytes (especially potassium and sodium) every 2-4 hours initially. Monitor vital signs, urine output, and mental status closely. 4. Patient Safety and Precautions: * Hypoglycemia Risk: When blood glucose falls to around 200-250 mg/dL, dextrose must be added to the IV fluids to prevent hypoglycemia while continuing the insulin drip until ketosis clears. * Hypokalemia Risk: Insulin drives potassium into cells. Serum potassium will drop rapidly. Potassium replacement via IV is almost always required, even if the initial level is normal or high. * Fluid Overload Risk: Monitor for crackles in lungs and increased respiratory rate, especially in older adults or those with heart failure. Nursing Procedure & Medication Flow IV Regular Insulin Administration in DKA: 1. Preparation: Confirm the order for a continuous IV insulin infusion. Standard protocol: Add 100 units of regular insulin to 100 mL of 0.9% NS (concentration: 1 unit/mL). 2. Administration: Administer via an infusion pump. The initial bolus is often omitted in current guidelines. The standard starting dose is 0.1 unit/kg/hour. 3. Titration: Titrate the drip based on hourly blood glucose checks, aiming for a blood glucose decrease of 50-75 mg/dL per hour. 4. Transition: Once the patient is stable, ketosis is resolved, and can tolerate oral intake, transition to subcutaneous insulin. Overlap the subcutaneous dose with the IV infusion for 1-2 hours to prevent rebound hyperglycemia. A Word from Your Senior Nurse "In DKA, think of insulin as the firefighter putting out the metabolic fire. Fluids are the water hydrating the scene, and potassium is the safety check to make sure the floor doesn't collapse. Your critical thinking in prioritizing the insulin drip, while vigilantly monitoring for the complications of treatment (hypoglycemia, hypokalemia), is what saves lives. On the NCLEX, they love to test the 'priority' in metabolic emergencies. Always ask yourself: 'What intervention stops the primary pathological process?' That's your answer."