# Stage 3 — Prioritize hypotheses. A 42-year-old client with type 1 diabetes has had nausea, vomiting, and abdominal pain for 2 days and has taken no basal or bolus insulin for 36 hours. She drinks wine socially but none in 2 weeks. BP is 100/64, HR 112, RR 26 with deep, regular breathing, temperature 37.2°C (99°F), and SpO2 98%. She is alert and oriented, her oral mucosa is dry, and she has voided twice in 24 hours. Results: glucose 478 mg/dL, beta-hydroxybutyrate 6.8 mmol/L, venous pH 7.18, bicarbonate 9 mmol/L, and serum potassium 5.8 mmol/L. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

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

## Question

Stage 3 — Prioritize hypotheses. A 42-year-old client with type 1 diabetes has had nausea, vomiting, and abdominal pain for 2 days and has taken no basal or bolus insulin for 36 hours. She drinks wine socially but none in 2 weeks. BP is 100/64, HR 112, RR 26 with deep, regular breathing, temperature 37.2°C (99°F), and SpO2 98%. She is alert and oriented, her oral mucosa is dry, and she has voided twice in 24 hours. Results: glucose 478 mg/dL, beta-hydroxybutyrate 6.8 mmol/L, venous pH 7.18, bicarbonate 9 mmol/L, and serum potassium 5.8 mmol/L. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Condition

Select 1
Hyperosmolar hyperglycemic state
Diabetic ketoacidosis
Alcoholic ketoacidosis
Starvation ketosis

Actions to take

Select 2
Give prescribed IV sodium bicarbonate
Add potassium chloride to the first liter of fluid
Begin the prescribed isotonic IV fluid
Give subcutaneous insulin glargine as the only insulin
Start the prescribed IV regular insulin infusion

Parameters to monitor

Select 2
Serum osmolality
Serum potassium
Urine ketone dipstick
Serum lipase level
Serum bicarbonate

## Explanation

Glucose 478 mg/dL, beta-hydroxybutyrate 6.8 mmol/L, pH 7.18, and bicarbonate 9 mmol/L after 36 hours without insulin meet the criteria for DKA. Isotonic fluid begins first and the IV regular insulin infusion can start because potassium is above 3.5 mmol/L. Serum potassium must be trended because insulin will drive it down, and bicarbonate (with the anion gap) shows whether the acidosis is resolving.

## In-depth explanation

Quick answer
Diabetic ketoacidosis. Begin the prescribed isotonic IV fluid and start the IV regular insulin infusion. Monitor serum potassium and serum bicarbonate.

Why this is correct
Without insulin, fat breakdown produces ketoacids, causing ketonemia, a low pH and bicarbonate, Kussmaul respirations, and osmotic diuresis with volume loss. Fluids restore perfusion first, and IV insulin stops ketone production; insulin is safe to start because potassium is 5.8 mmol/L. The initial high potassium reflects a shift out of cells, while total body potassium is depleted, so potassium falls quickly once insulin and fluids are running.

Easy analogy or mental picture
In DKA the cells are starving in a sea of sugar because the door (insulin) is locked. Fluids refill the tank, insulin opens the door, and potassium rushes back into the cells with the sugar, so the blood level drops fast.

Memory hook
"Fluids first, then insulin if K is above 3.5; watch K and the bicarbonate close."

NCLEX decision rule
In DKA, check potassium before starting insulin, and judge recovery by acid-base values and potassium rather than glucose alone.

Why the other choices are wrong
HHS needs a high osmolality with minimal ketones and a near-normal pH; this pH of 7.18 with high ketones is DKA, so osmolality is not the key response measure. Alcoholic ketoacidosis needs recent heavy drinking with usually low or normal glucose, and starvation ketosis does not cause glucose 478 or a pH of 7.18. Bicarbonate is not indicated at pH 7.18, and adding potassium is right later but not while potassium is 5.8 mmol/L. Glargine alone is too slow to treat DKA. Urine dipsticks measure acetoacetate and lag behind blood ketones, and lipase would matter only if pancreatitis were suspected.

References
1Hyperglycemic Crises in Adults With Diabetes: A Consensus Report (Diabetes Care, 2024)DKA criteria include euglycemic presentations; beta-hydroxybutyrate, pH/bicarbonate, and potassium guide fluid and insulin therapy
2Adult Diabetic Ketoacidosis (StatPearls)Isotonic fluids, IV insulin once potassium is at least 3.3 mEq/L, and serial electrolyte, ketone, and acid-base monitoring

## Clinical scenario

Case update
Laboratory results confirm hyperglycemia, ketonemia, and metabolic acidosis with an elevated potassium before treatment.

## Key concepts

- **Kussmaul respirations** — Deep, rapid breathing that blows off carbon dioxide to compensate for metabolic acidosis.
- **Potassium shift** — Movement of potassium out of cells in acidosis and insulin deficiency, and back into cells when insulin is given.
- **DKA resolution** — Ketones below 0.6 mmol/L plus a venous pH of at least 7.3 or bicarbonate of at least 18 mmol/L.

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