# Stage 4 — Generate solutions. Review the confirmed DKA findings in the EHR. Which interventions should the nurse implement now or anticipate during treatment? Select all that apply.

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> subject: Expected Actions/Outcomes  
> category: PPT

## Question

Stage 4 — Generate solutions. Review the confirmed DKA findings in the EHR. Which interventions should the nurse implement now or anticipate during treatment? Select all that apply.

1

Continue prescribed isotonic saline or balanced crystalloid, using an initial rate appropriate to hemodynamics and adjusting for fluid balance and cardiac or renal status

2

Begin IV regular insulin under the DKA protocol after confirming potassium is above 3.5 mmol/L, with continuous cardiac and clinical monitoring

3

Measure potassium serially and add replacement after it falls below 5.0 mmol/L, adjusting therapy to maintain a serum level of 4 to 5 mmol/L

4

Check glucose every 1 to 2 hours and key laboratory markers about every 4 hours; add 5 to 10 percent dextrose when glucose falls below 250 mg/dL

5

Continue insulin until ketonemia and acidosis resolve while evaluating and addressing insulin omission, infection, ischemia, medication effects, and other precipitants

6

Give routine IV sodium bicarbonate during the first hour for pH 7.18 and stop insulin as soon as the anion gap becomes normal even if beta-hydroxybutyrate remains elevated

## Explanation

Five appropriate interventions
Correct care combines individualized isotonic fluid; potassium-safe IV insulin; serial potassium replacement planning; glucose and biochemical monitoring with dextrose below 250 mg/dL; and continued insulin plus precipitant management until ketonemia and acidosis resolve. Routine bicarbonate is not recommended at pH 7.18, and anion gap alone should not determine resolution.

## In-depth explanation

Step 1 — Restore volume and give insulin safely
Use isotonic saline or balanced crystalloid and individualize the rate. Because potassium is 5.8 mmol/L, prescribed IV insulin can begin; insulin would be delayed only if potassium were below 3.5 mmol/L.

Step 2 — Anticipate potassium movement
Total-body potassium is depleted even when the serum value is initially high. Begin replacement after serum potassium falls below 5.0 mmol/L and adjust to maintain 4 to 5 mmol/L.

Step 3 — Continue insulin beyond glucose correction
When glucose falls below 250 mg/dL, add 5 to 10 percent dextrose and reduce insulin as prescribed so ketonemia can clear without hypoglycemia. Follow beta-hydroxybutyrate and acid-base status rather than urine ketones or anion gap alone.

Step 4 — Avoid routine bicarbonate
The consensus recommends considering bicarbonate only for severe acidosis around pH below 7.0. It is not routine treatment for this pH of 7.18.

NCLEX rule
Select coordinated fluid, insulin, electrolyte, monitoring, and precipitant care.

## Clinical scenario

Scenario (Stage 4 — Generate solutions)
The DKA protocol has begun and the nurse anticipates treatment-driven changes in glucose and potassium.

Clinical judgment target
Select the complete treatment and monitoring bundle and reject premature biochemical endpoints.

## Key concepts

- **Dextrose during DKA treatment** — Dextrose is added below 250 mg/dL so insulin can continue safely until ketonemia resolves.
- **Total-body potassium deficit** — Body potassium is depleted through urinary and gastrointestinal losses even when acidosis initially raises the serum level.
- **Bicarbonate exception** — Routine bicarbonate is not recommended; it may be considered when metabolic acidosis is severe, such as pH below 7.0.

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