Nokea
The nurse is caring for a 20-year-old female client.
Nurses' Notes
Urgent Care Clinic
0845: The parent brought the client to the clinic due to vomiting and weakness. The parent states that the client has experienced
sore throat and nasal congestion for the past week. The client has had 4 episodes of emesis during the past 24 hours and
diffuse, constant abdominal pain. The parent also reports that the client has had increased thirst and urine output over the
past 2 months.
The client's last menstrual period ended approximately 6 weeks ago with no abnormalities. Pregnancy status is unknown. The
client does not take any medications and does not use tobacco, alcohol, or recreational substances. Family history includes
hypertension and diabetes mellitus.
The client appears drowsy and is oriented to person and time only. The abdomen is soft without rigidity or rebound
tenderness, and bowel sounds are normal. No blood is present in emesis. Respirations are rapid and deep. Breath sounds
are clear.
Vital signs are T 98.8 F (37.1 C), P 128, RR 30, and BP 88/60 mm Hg.
Finger-stick blood glucose level is 600 mg/dL (33.3 mmol/L).
Laboratory Results
Laboratory Test and Reference Range, 0900
Glucose, serum (random)
≤200 mg/dL
(<11.1 mmol/L),
573 mg/dL
(31.8 mmol/L)
Potassium
3.5-5.0 mEq/L
(3.5-5.0 mmol/L),
5.7 mEq/L
(5.7 mmol/L)
The nurse has reviewed the information from the Laboratory Results. The client is transferred to an inpatient care facility. Which of the following orders should the nurse expect for the client? Select all that apply
Correct Answer: A,B,C,G
Rationale: Management of diabetic ketoacidosis (DKA) initially focuses on IV fluid resuscitation to reverse hypovolemia and then correction of
hyperglycemia, electrolyte abnormalities, and acid-base imbalance. Appropriate interventions include:
• Continuous insulin IV infusion to correct hyperglycemia. IV insulin has a more rapid onset of action than subcutaneous insulin, whic
allows faster and more precise management of the blood glucose level (Option 1).
• Continuous cardiac monitoring to detect dyshythmias related to metabolic acidosis or electrolyte abnormalities (Option 2).
• Hourly finger-stick blood glucose level checks to monitor for treatment effectiveness and detect any hypoglycemia related to the
insulin infusion (Option 3).
• Isotonic IV fluid (eg, 0.9% sodium chloride) to replace fluid losses and strict intake and output monitoring to evaluate the
effectiveness of fluid resuscitation and monitor for signs of acute kidney injury (Option 6).
• Frequent monitoring of arterial blood gas levels and electrolyte levels.