# Stage 1 — Recognize cues. A 42-year-old client is evaluated in the emergency department. Review the nurse's note. Highlight the findings that require immediate follow-up.

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> language: en  
> subject: Expected Actions/Outcomes  
> category: PPT

## Question

Stage 1 — Recognize cues. A 42-year-old client is evaluated in the emergency department. Review the nurse's note. Highlight the findings that require immediate follow-up.

A 42-year-old client with type 1 diabetes for 20 years reports nausea, vomiting, and abdominal pain for 2 days. Her regimen is insulin glargine nightly with lispro at meals, but she has taken no basal or bolus insulin for 36 hours because she has not been eating. Her last A1C of 7.4 percent 3 months ago was near her target. She had a sore throat last week that has resolved and drinks wine socially, none in 2 weeks. At an endocrine visit last month, BP was 122/78 and HR 76. Now: BP 100/64 and HR 112, RR 26 with deep, regular breathing, and T 37.2 C and SpO2 98 percent on room air. She is alert, oriented, and answering promptly. Oral mucosa is dry, and she has voided twice in the past 24 hours.

## Explanation

Stopping basal as well as bolus insulin for 36 hours in type 1 diabetes removes the insulin that suppresses ketogenesis, so it requires immediate follow-up even though she was not eating. RR 26 with deep, regular breathing and normal SpO2 suggests respiratory compensation for metabolic acidosis rather than a lung problem, and BP 100/64 with HR 112 is a clear drop from her 122/78 and 76 baseline. Voiding only twice in 24 hours despite hyperglycemia-driven diuresis signals volume depletion. The resolved sore throat, near-normal temperature, occasional wine, and good A1C are tempting but do not point to the current crisis.

## In-depth explanation

Quick answer
Highlight the 36-hour omission of all insulin, BP 100/64 with HR 112, RR 26 with deep regular breathing, and voiding only twice in 24 hours.

Why this is correct
In type 1 diabetes, basal insulin is needed even without food; omitting it lets ketones accumulate. Deep, regular, rapid breathing with SpO2 98 percent points to compensation for metabolic acidosis, not hypoxemia. Compared with last month's 122/78 and 76, the current BP and HR show volume loss, and scant voiding confirms it.

Easy analogy or mental picture
Basal insulin is the brake that keeps the fat-burning engine idling. Taking your foot off the brake because you are not "driving" (eating) still lets the engine race and produce exhaust (ketones).

Memory hook
No food still needs basal: sick-day rule. Deep breaths with a normal SpO2 are blowing off acid.

NCLEX decision rule
When breathing is fast and deep but oxygenation is normal, think metabolic acidosis. When vital signs look only mildly abnormal, compare them with the documented baseline before discounting them.

Why the other choices are wrong
The resolved sore throat and T 37.2 C tempt as an infection source, but the throat has resolved and she is afebrile; infection is still evaluated later, yet these findings are not the current red flag. Occasional wine with none in 2 weeks makes alcoholic ketoacidosis unlikely. A1C 7.4 percent reflects prior control, not today's state. Being alert and oriented is reassuring and actually argues against a hyperosmolar presentation. Twenty years of type 1 diabetes and her usual regimen are background; the omission, not the regimen, is the cue.

References
1Hyperglycemic Crises in Adults With Diabetes: A Consensus Report (Diabetes Care, 2024)Insulin omission is a leading DKA precipitant; Kussmaul respirations, volume depletion, and tachycardia are typical findings
2ADA Standards of Care in Diabetes—2025People with type 1 diabetes need continued basal insulin and sick-day management during illness

## Clinical scenario

Scenario (Stage 1 — Recognize cues)
A client with type 1 diabetes has vomited for 2 days and stopped all insulin because she was not eating. Laboratory results are not yet available.

Clinical judgment target
Recognize insulin omission, compensatory breathing, and volume depletion before laboratory confirmation while setting aside reassuring or background findings.

## Key concepts

- **Kussmaul respirations** — Deep, regular, rapid breathing that lowers PaCO2 to compensate for metabolic acidosis.
- **Sick-day rules** — Guidance to continue basal insulin, monitor glucose and ketones, and seek care during illness even when intake is poor.
- **Osmotic diuresis** — Urine loss driven by glucose in the renal tubules that leads to volume depletion and later reduced urine output.

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