# A 24-year-old client with type 1 diabetes is admitted with diabetic ketoacidosis after missing insulin for 2 days. The first liter of 0.9% sodium chloride is infusing. Laboratory results: glucose 480 mg/dL, pH 7.12, bicarbonate 10 mEq/L, anion gap 26, potassium 3.1 mEq/L, sodium 131 mEq/L. The provider has entered the hospital DKA order set, which includes a continuous IV regular insulin infusion and IV potassium chloride per protocol. Which actions should the nurse take? Select all that apply.

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## Question

A 24-year-old client with type 1 diabetes is admitted with diabetic ketoacidosis after missing insulin for 2 days. The first liter of 0.9% sodium chloride is infusing. Laboratory results: glucose 480 mg/dL, pH 7.12, bicarbonate 10 mEq/L, anion gap 26, potassium 3.1 mEq/L, sodium 131 mEq/L. The provider has entered the hospital DKA order set, which includes a continuous IV regular insulin infusion and IV potassium chloride per protocol. Which actions should the nurse take? Select all that apply.

1

Request IV sodium bicarbonate because the arterial pH is below 7.20

2

Keep the client on continuous cardiac monitoring during infusions

3

Recheck the serum potassium level before the insulin infusion starts

4

Begin IV potassium replacement before starting the insulin infusion

5

Request 3% saline to raise the sodium level of 131 mEq/L right away

6

Give an IV regular insulin bolus now, then start the insulin infusion

## Explanation

With potassium 3.1 mEq/L, insulin is delayed and potassium replaced first, because insulin drives potassium into cells and can cause dangerous hypokalemia and dysrhythmias; potassium is rechecked before insulin starts and cardiac monitoring continues. Bicarbonate is reserved for pH below 7.0, an insulin bolus adds a sudden potassium shift, and the sodium is pseudohyponatremia from hyperglycemia (corrected sodium about 137 mEq/L).

## In-depth explanation

Quick answer
Replace potassium first, recheck it before insulin, and keep cardiac monitoring.

Why this is correct
The discriminating detail is the potassium of 3.1 mEq/L. Although total-body potassium is depleted in DKA, the order set's insulin infusion would shift the remaining potassium into cells; current consensus holds insulin until potassium is at least 3.5 mEq/L while giving fluids and potassium. The nurse therefore sequences the order set rather than starting everything at once, rechecks potassium, and monitors the ECG for hypokalemic changes.

Easy analogy or mental picture
Insulin is a doorman that ushers potassium into the cells; if the hallway (serum) is already nearly empty, open the door and the heart is left with nothing.

Memory hook
K below 3.5: potassium before insulin.

NCLEX decision rule
In DKA, check potassium before insulin: fluids first, potassium replacement if low, insulin only once potassium is adequate.

Why the other choices are wrong
An insulin bolus is still taught in many courses and appears in older protocols, but it is optional at best and here would worsen hypokalemia. Bicarbonate is tempting because the pH is well below normal, yet guidelines limit it to pH below 7.0 because it can worsen hypokalemia and has no outcome benefit at 7.12. Sodium 131 mEq/L looks like true hyponatremia, but correcting for a glucose of 480 mg/dL gives about 137 mEq/L, so hypertonic saline would be harmful.

References
1Diabetes Care (American Diabetes Association journal)2024 ADA/EASD/JBDS/AACE/DTS consensus report on hyperglycemic crises: potassium threshold before insulin and bicarbonate use
2ADA Standards of Care in Diabetes—2025 (Diabetes Care Supplement 1)Management of hyperglycemic crises in adults with diabetes

## Clinical scenario

Scenario
Type 1 diabetes with DKA (glucose 480 mg/dL, pH 7.12, bicarbonate 10 mEq/L) and admission potassium 3.1 mEq/L; fluids started, DKA order set active.

## Key concepts

- **Pseudohyponatremia (translocational)** — A low measured sodium caused by hyperglycemia drawing water into the serum; corrected by adding about 1.6 mEq/L per 100 mg/dL of glucose above 100.
- **Potassium shift** — Movement of potassium from serum into cells caused by insulin, which can rapidly lower serum levels.
- **Anion gap metabolic acidosis** — Acidosis with an increased anion gap, caused in DKA by accumulated ketoacids.

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