# Stage 6 — Evaluate outcomes. Review the 6-hour trend and select the best interpretation and next plan using current DKA resolution criteria.

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> url: https://mymerci.kr/pages/nclex_q.php?qn_id=372661&lang=en  
> language: en  
> subject: Expected Actions/Outcomes  
> category: PPT

## Question

Stage 6 — Evaluate outcomes. Review the 6-hour trend and select the best interpretation and next plan using current DKA resolution criteria.

| Time | Data |
| --- | --- |
| Hour 0 | Glucose 478 mg/dL; beta-hydroxybutyrate 6.8 mmol/L; venous pH 7.18; bicarbonate 9 mmol/L; K 5.8 mmol/L; urine output 20 mL/h; isotonic fluid started |
| Hour 2 | Glucose 320 mg/dL; beta-hydroxybutyrate 3.8 mmol/L; venous pH 7.24; bicarbonate 12 mmol/L; K 4.2 mmol/L; urine output 40 mL/h; IV insulin running |
| Hour 4 | Glucose 195 mg/dL; beta-hydroxybutyrate 1.2 mmol/L; venous pH 7.29; bicarbonate 16 mmol/L; K 3.8 mmol/L; dextrose added and insulin continued |
| Hour 6 | Glucose 168 mg/dL; beta-hydroxybutyrate 0.4 mmol/L; venous pH 7.32; bicarbonate 19 mmol/L; K 4.1 mmol/L; urine output 60 mL/h; tolerating oral intake |

Q1. How is the client responding to therapy?

Clinically improving with DKA resolution criteria now met
Glucose is improving but ketoacidosis is worsening
The client remains unchanged because glucose is not below 100 mg/dL

Q2. What is the best next plan?

Give the planned basal-bolus insulin with at least 1 to 2 hours of IV overlap; continue monitoring and complete sick-day and insulin-access planning
Stop IV insulin immediately without subcutaneous insulin because the anion gap would now be normal
Continue the same IV insulin indefinitely until urine ketones are absent
Give sodium bicarbonate now because venous pH has not reached 7.40

## Explanation

Trend interpretation
At hour 6, beta-hydroxybutyrate is below 0.6 mmol/L, pH is at least 7.3, bicarbonate is at least 18 mmol/L, and glucose is below 200 mg/dL, so DKA resolution criteria are met. Give the planned basal-bolus insulin with at least 1 to 2 hours of IV overlap, continue safety monitoring, and address sick-day insulin use and the cause of omission before discharge.

## In-depth explanation

Step 1 — Follow the whole trajectory
Glucose, beta-hydroxybutyrate, pH, bicarbonate, potassium, perfusion, and urine output all improve. Dextrose was appropriately added when glucose fell below 250 mg/dL so insulin could continue clearing ketones.

Step 2 — Apply current resolution criteria
Resolution requires beta-hydroxybutyrate below 0.6 mmol/L and venous pH at least 7.3 or bicarbonate at least 18 mmol/L; glucose is ideally below 200 mg/dL. Anion gap and urine ketones should not be used as the primary resolution endpoint because treatment can make them misleading.

Step 3 — Transition without an insulin gap
Administer basal-bolus subcutaneous insulin with at least 1 to 2 hours of overlap before stopping IV insulin. The purpose is to prevent rebound hyperglycemia and recurrent ketoacidosis.

Step 4 — Prevent recurrence
Before discharge, confirm access to insulin and monitoring supplies, teach that basal insulin generally continues during illness unless specifically directed otherwise, review glucose and ketone monitoring and when to seek help, and address the actual reason for insulin omission.

NCLEX rule
Resolution requires ketone and acid-base recovery plus a safe transition and recurrence-prevention plan.

## Clinical scenario

Scenario (Stage 6 — Evaluate outcomes)
Determine whether ketoacidosis has resolved and choose a transition plan that avoids an insulin gap.

Clinical judgment target
Use beta-hydroxybutyrate and acid-base recovery rather than anion gap alone.

## Key concepts

- **Biochemical DKA resolution** — Beta-hydroxybutyrate below 0.6 mmol/L with venous pH at least 7.3 or bicarbonate at least 18 mmol/L.
- **Rebound ketoacidosis** — Recurrence caused by an interruption in effective insulin or unresolved precipitating factors after IV therapy is stopped.
- **Sick-day plan** — Instructions for continuing insulin, monitoring glucose and ketones, hydration, carbohydrate intake, clinician contact, and emergency warning signs during illness.

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