# A nurse is caring for an adult client admitted with diabetic ketoacidosis. Laboratory results show glucose 540 mg/dL, pH 7.18, HCO3 12 mEq/L, and anion gap 22. Which interventions should the nurse anticipate as part of evidence-based DKA management? Select all that apply.

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> language: en  
> subject: Medical Emergencies  
> category: PA

## Question

A nurse is caring for an adult client admitted with diabetic ketoacidosis. Laboratory results show glucose 540 mg/dL, pH 7.18, HCO3 12 mEq/L, and anion gap 22. Which interventions should the nurse anticipate as part of evidence-based DKA management? Select all that apply.

1

Withhold IV fluids until blood glucose normalizes to baseline to prevent the risk of fluid overload

2

Start a continuous IV regular insulin infusion at approximately 0.1 unit/kg/hr after fluid resuscitation has begun

3

Switch the IV fluid to a 5 percent dextrose-containing solution when blood glucose drops to about 200 to 250 mg/dL while continuing the insulin infusion

4

Begin subcutaneous rapid-acting insulin on a sliding scale at 4-hour intervals as the primary treatment for the metabolic acidosis

5

Measure serum potassium 2 hours after starting insulin and every 4 hours thereafter; add potassium to IV fluids once serum potassium falls below 5.0 mEq/L to maintain a level of 4 to 5 mEq/L

6

Initiate rapid IV isotonic fluid resuscitation with 0.9 percent normal saline before starting insulin therapy

## Explanation

DKA management begins with isotonic IV fluid resuscitation (Choice 6), with adjustments for clients at high risk of fluid overload. Continuous IV short-acting insulin at 0.1 unit/kg/hr is standard for DKA (Choice 2), whereas subcutaneous sliding-scale insulin alone does not treat the ketoacidosis (Choice 4). Because insulin and correction of acidosis lower serum potassium, measure potassium 2 hours after insulin begins and every 4 hours thereafter; start potassium replacement when the level falls below 5.0 mEq/L to maintain 4–5 mEq/L (Choice 5). When glucose falls below about 250 mg/dL, add 5–10% dextrose to the IV fluid and continue insulin until ketoacidosis resolves (Choice 3). Withholding IV fluid until glucose normalizes (Choice 1) is unsafe.

## In-depth explanation

DKA Management Order
1. Fluids first: 0.9% NS bolus, then 0.45% NS once perfusion restored
2. Insulin infusion: 0.1 unit/kg/hr IV regular (no SC sliding scale)
3. Potassium: hourly check, replace if K < 5.0 (insulin drives K into cells)
4. Add dextrose when glucose 200-250 to continue insulin without hypoglycemia
5. Monitor: glucose hourly, BMP q2-4h, anion gap, mentation

When to Stop the Insulin Drip
When anion gap closes, HCO3 ≥ 18, pH ≥ 7.30, AND client tolerates oral intake. Overlap SC long-acting insulin 1-2 hr BEFORE stopping IV (otherwise rebound DKA).

Memory Tip — "FIPD"
Fluids first, Insulin drip, Potassium watch, Dextrose at 200-250.

Caution
Do NOT give insulin if K < 3.3 mEq/L — replace K first. Cerebral edema is the deadliest pediatric DKA complication; avoid overly rapid glucose correction.

## Clinical scenario

Scenario
Adult, DKA: glucose 540, pH 7.18, HCO3 12, K 5.2, AG 22. Symptoms: polyuria, polydipsia × 2 days, nausea, fruity breath, Kussmaul respirations, mild lethargy.

Initial Order Set
- 1 L NS bolus over 1 hr; reassess
- Insulin regular drip 0.1 unit/kg/hr after bolus started
- Hourly fingerstick glucose
- BMP q2h with K replacement
- Strict I&O, foley if obtunded
- Search for trigger: infection, missed insulin, MI, pancreatitis

Resolution Criteria
Glucose < 200 + 2 of: HCO3 ≥ 15, venous pH ≥ 7.30, anion gap ≤ 12. Then transition to SC insulin with overlap.

## Key concepts

- **DKA diagnostic triad** — Hyperglycemia (glucose ≥ 250 mg/dL), anion gap metabolic acidosis (pH < 7.30, HCO3 < 18, AG > 12), and ketosis (positive serum/urine ketones). Common triggers: infection, missed insulin, new-onset T1DM, MI, pancreatitis, surgery.
- **Insulin and potassium relationship** — Insulin drives extracellular potassium into cells. DKA clients usually have total-body K depletion despite normal or elevated serum K (acidosis pushes K out). Once insulin starts, serum K can drop rapidly and cause life-threatening dysrhythmias. Replace K early; never start insulin if K < 3.3.
- **Dextrose addition during DKA** — When glucose falls to 200-250 mg/dL during insulin therapy, add D5W or D5-0.45% NS to maintain glucose around 150-200 while continuing the insulin infusion. This allows continued correction of the underlying acidosis (the goal) without inducing hypoglycemia.

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