# Stage 1 — Recognize cues. Highlight the findings that require immediate follow-up.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=617255&lang=en  
> language: en  
> subject: Medical Emergencies  
> category: PA

## Question

Stage 1 — Recognize cues. Highlight the findings that require immediate follow-up.

A 26-year-old adult with type 1 diabetes presents after 18 hours of nausea, vomiting, polyuria, and progressive weakness. The pump tubing is still kinked, and the client reports receiving little insulin since the previous evening. The client had two beers four days ago and has not eaten since yesterday. The client is alert; the abdomen is soft without guarding or rebound, and the client reports diffuse abdominal discomfort that began with the vomiting. The A1C was 9.8% last month. Vital signs: HR 124/min, deep respirations at 30/min, BP 96/60 (usual 124/78), temperature 37.2 C, SpO2 98% on room air. Laboratory results: glucose 462 mg/dL, beta-hydroxybutyrate 5.8 mmol/L, venous pH 7.19, bicarbonate 10 mmol/L, potassium 5.4 mmol/L, serum sodium 130 mmol/L, creatinine 1.5 mg/dL, white blood cells 16,800/mm3 with no bands, and effective osmolality 286 mOsm/kg. Urinalysis shows glucose and ketones and is negative for nitrites and leukocyte esterase.

## Explanation

The kinked tubing is an ongoing cause of insulin deficiency, deep rapid respirations are respiratory compensation for acidosis, beta-hydroxybutyrate 5.8 mmol/L with bicarbonate 10 mmol/L defines significant ketoacidosis, and a BP well below the usual value reflects volume depletion. The measured sodium corrects to the normal range for a glucose of 462 mg/dL, leukocytosis without bands, a normal temperature, and a negative urinalysis fit stress leukocytosis of DKA, discomfort that began with vomiting in a soft abdomen fits acidosis, the effective osmolality of 286 mOsm/kg is far below the HHS range, and remote light alcohol use and a high A1C do not explain the acute state.

## In-depth explanation

Quick answer
Kinked pump tubing, deep respirations at 30/min, BP 96/60 (usual 124/78), beta-hydroxybutyrate 5.8 mmol/L, and bicarbonate 10 mmol/L.

Why this is correct
A pump user has no long-acting insulin on board, so a kinked line produces ketoacidosis within hours and remains an active cause until the pump is removed and intravenous insulin replaces it. Severity in DKA is judged by ketones, bicarbonate, and pH rather than by glucose, which is only moderately elevated here and well below the typical HHS range. Kussmaul breathing shows the body is compensating for acidosis, and a systolic pressure 28 mm Hg below this client's usual value with tachycardia confirms clinically important volume loss.

Easy analogy or mental picture
Picture the pump as a garden hose with a kink: the tap is on, but nothing reaches the garden, and the ketone weeds grow within hours.

Memory hook
"Ketones and bicarb grade DKA; glucose only starts the conversation."

NCLEX decision rule
In a suspected hyperglycemic crisis, prioritize the cause that is still active, the acid-base severity, and perfusion; correct sodium for glucose and interpret leukocytosis and abdominal pain in light of the acidosis before chasing another diagnosis.

Why the other choices are wrong
Sodium 130 mmol/L looks like hyponatremia, but correcting for a glucose of 462 mg/dL gives about 136 to 139 mmol/L. WBC 16,800/mm3 suggests infection, yet there are no bands, the temperature is 37.2 C, the urinalysis is negative, and the precipitant is already identified, so this is the stress leukocytosis typical of DKA. Diffuse abdominal discomfort that began with the vomiting in a soft abdomen without guarding or rebound is the acidosis-related pain of DKA; it is reassessed only if it persists after acidosis improves. An effective osmolality of 286 mOsm/kg (2 x 130 + 462/18) is tempting to link to a hyperosmolar crisis, but HHS requires about 300 mOsm/kg or more with little ketosis. Two beers four days ago do not support alcoholic ketoacidosis, which follows heavy recent drinking with low or normal glucose. An A1C of 9.8% reflects chronic control, not the acute crisis.

References
1Hyperglycemic Crises in Adults With Diabetes: A Consensus Report (Diabetes Care, 2024)DKA diagnostic criteria, severity by bicarbonate and pH, corrected sodium, leukocytosis and abdominal pain in DKA, distinction from HHS
2ADA Standards of Care in Diabetes—2025Insulin-pump failure as a DKA precipitant and hyperglycemic-crisis management

## Clinical scenario

Case update
Initial assessment — a client with type 1 diabetes has received little pump insulin for about 18 hours and now has vomiting and weakness.

## Key concepts

- **Diabetic ketoacidosis** — An insulin-deficiency crisis with ketonemia, metabolic acidosis (low bicarbonate and pH), and usually hyperglycemia.
- **Corrected sodium** — The sodium adjusted for hyperglycemia, which draws water into the vascular space and lowers measured sodium.
- **Kussmaul respirations** — Deep, rapid breathing that compensates for metabolic acidosis by eliminating carbon dioxide.

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