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Diabetic Emergencies: Recognition And Treatment - NCLEX Rn

  1. A 73-year-old woman with type 2 diabetes is admitted with HHS after 4 days of poor intake and a respiratory infection. Vital signs: BP 90/54 mm Hg, HR 128/min, RR 22/min, T 38.2°C (100.8°F); glucose 1,040 mg/dL. Labs: serum osmolality 352 mOsm/kg (normal 275–295), pH 7.40 (normal 7.35–7.45), HCO3− 25 mEq/L (normal 22–26), serum ketones negative (normal negative). What is the nurse's PRIORITY intervention for this patient?
    Answer: Start isotonic IV fluids and monitor hemodynamic response closely This question tests recognition and treatment of diabetic emergencies, specifically hyperosmolar hyperglycemic state (HHS) in an elderly type 2 diabetes patient with infection and poor intake. The priority concern is correcting severe dehydration and hypotension to restore organ perfusion. Starting isotonic IV fluids and monitoring hemodynamic response closely is the best choice as it addresses the massive fluid deficit from osmotic diuresis in HHS. Obtaining urine ketones delays care and is unnecessary in non-ketotic HHS; administering IV dextrose risks worsening hyperglycemia; and delegating IV rate adjustments exceeds UAP scope. This uses the ABC framework, prioritizing circulation. Clinical judgment involves recognizing HHS requires 4-10 liters of fluid initially. A transferable strategy is to prioritize volume resuscitation in HHS before insulin, assessing urine output and vital signs frequently.
  2. A 19-year-old man with type 1 diabetes presents with polyuria, polydipsia, and abdominal pain after missing insulin due to a sore throat and fever. Vital signs: blood glucose 480 mg/dL, blood pressure 100/64 mm Hg, heart rate 112/min, respiratory rate 26/min. Labs: arterial pH 7.22 (normal 7.35–7.45), bicarbonate 14 mEq/L (normal 22–26), anion gap 22 mEq/L (normal 8–12), potassium 5.6 mEq/L (normal 3.5–5.0), serum ketones positive (normal negative). The provider writes several orders. The nurse should QUESTION which treatment order for this patient?
    Answer: Administer potassium chloride 40 mEq intravenously now This question tests recognition and treatment of diabetic emergencies, specifically recognizing contraindications in DKA management. The priority concern is preventing cardiac complications from inappropriate potassium administration. The nurse should question administering potassium chloride 40 mEq intravenously now because the patient has hyperkalemia (5.6 mEq/L), making additional potassium dangerous and potentially causing cardiac arrhythmias or arrest. Starting isotonic fluids (A) is appropriate for dehydration; insulin infusion with monitoring (B) will help correct hyperglycemia and acidosis while lowering potassium; obtaining serial labs (D) is essential for monitoring. The clinical judgment principle is recognizing absolute contraindications - never give potassium when serum levels are elevated, even though total body stores are depleted. A transferable strategy is understanding that initial hyperkalemia in DKA results from acidosis-induced cellular shifts, and levels will drop with treatment, requiring close monitoring but not immediate supplementation.
  3. A 27-year-old woman with type 1 diabetes is admitted for DKA after a skin infection. Vital signs: BP 94/58 mm Hg, HR 122/min, RR 30/min (deep), T 38.2°C (100.8°F); glucose 540 mg/dL. Labs: pH 7.09 (normal 7.35–7.45), HCO3− 8 mEq/L (normal 22–26), anion gap 30 mEq/L (normal 8–12), potassium 4.8 mEq/L (normal 3.5–5.0). What is the nurse's PRIORITY intervention to implement first?
    Answer: Start 0.9% sodium chloride IV bolus and reassess circulatory status This question tests recognition and treatment of diabetic emergencies, focusing on initial steps in severe diabetic ketoacidosis (DKA) for a type 1 diabetes patient. The priority concern is correcting dehydration before addressing hyperglycemia to avoid exacerbating hypotension. Starting 0.9% sodium chloride IV bolus and reassessing circulatory status is the best choice as it restores volume, essential prior to insulin. Beginning IV insulin risks collapse; antiemetics are adjunctive; and repeat ABG is unnecessary with confirmed acidosis. This applies the ABC prioritization, ensuring circulation. Clinical judgment follows DKA protocols emphasizing fluids first. A transferable strategy is to assess vital signs and initiate fluids immediately in hypotensive DKA patients.
  4. A 66-year-old man with type 2 diabetes is confused and very thirsty after 1 week of dysuria and fever. Vital signs: BP 88/52 mm Hg, HR 130/min, RR 20/min, T 38.6°C (101.5°F); glucose 920 mg/dL. Labs: serum osmolality 338 mOsm/kg (normal 275–295), pH 7.34 (normal 7.35–7.45), HCO3− 20 mEq/L (normal 22–26), serum ketones trace (normal negative). What is the nurse's PRIORITY intervention for this patient with a mixed presentation?
    Answer: Start isotonic IV fluids and closely monitor airway, perfusion, and urine output This question tests recognition and treatment of diabetic emergencies, particularly a mixed DKA-HHS presentation in a type 2 diabetes patient with infection. The priority concern is stabilizing dehydration and potential airway compromise from altered mental status. Starting isotonic IV fluids and closely monitoring airway, perfusion, and urine output is the best choice as it addresses hypovolemia and supports organ function in this overlapping syndrome. Administering bicarbonate is not indicated with pH above 7.0; CT head is unnecessary without focal signs; and delegating anion gap interpretation exceeds LPN scope. This follows the ABC framework, ensuring airway and circulation first. Clinical judgment recognizes mixed presentations require fluid priority. A transferable strategy is to treat mixed diabetic emergencies with initial fluids, then insulin, while monitoring for acidosis resolution.
  5. A 67-year-old man with type 2 diabetes presents with weakness and confusion after 1 week of poor oral intake due to influenza. Vital signs: blood glucose 720 mg/dL, blood pressure 106/64 mm Hg, heart rate 104/min, respiratory rate 22/min. Labs: serum osmolality 318 mOsm/kg (normal 275–295), arterial pH 7.28 (normal 7.35–7.45), bicarbonate 16 mEq/L (normal 22–26), anion gap 18 mEq/L (normal 8–12), serum ketones trace (normal negative). What is the nurse's PRIORITY action to help differentiate DKA from HHS in this mixed presentation?
    Answer: Initiate isotonic intravenous fluids and obtain a venous blood gas and basic metabolic panel as ordered This question tests recognition and treatment of diabetic emergencies, specifically differentiating between DKA and HHS in mixed presentations. The priority concern is obtaining diagnostic information while initiating appropriate treatment for this patient with features of both conditions. Initiating isotonic intravenous fluids and obtaining labs is the best choice because it addresses the immediate need for fluid resuscitation while gathering data to clarify the diagnosis - the venous blood gas and metabolic panel will help determine the degree of acidosis and ketosis. Notifying about HHS alone (A) is premature given the mixed picture; delegating neurologic exams (C) is inappropriate; holding fluids (D) delays critical treatment. The clinical judgment principle is treating while investigating - fluid resuscitation benefits both conditions while diagnostic tests clarify the specific emergency. A transferable strategy is recognizing that initial management of DKA and HHS overlaps (fluid resuscitation), allowing treatment to begin while confirming the diagnosis.
  6. A 24-year-old man with type 1 diabetes presents with abdominal pain, nausea, and polyuria after a recent gastroenteritis. Vital signs: BP 100/62 mm Hg, HR 120/min, RR 28/min (deep), T 37.6°C (99.7°F); glucose 520 mg/dL. Labs: pH 7.10 (normal 7.35–7.45), HCO3− 9 mEq/L (normal 22–26), anion gap 28 mEq/L (normal 8–12), potassium 5.6 mEq/L (normal 3.5–5.0). The nurse should QUESTION which treatment order for this patient?
    Answer: Administer potassium chloride 40 mEq IV now This question tests recognition and treatment of diabetic emergencies, focusing on appropriate interventions for diabetic ketoacidosis (DKA) with initial hyperkalemia. The priority concern is safely managing electrolyte imbalances while treating acidosis and hyperglycemia. The nurse should question administering potassium chloride 40 mEq IV now because the patient's potassium is already elevated at 5.6 mEq/L, and insulin therapy will shift it intracellularly, potentially causing hypokalemia later but making immediate supplementation dangerous. Beginning 0.9% sodium chloride IV bolus addresses dehydration; starting IV insulin treats the underlying cause; and cardiac monitoring is prudent for electrolyte shifts. This applies clinical judgment by evaluating electrolyte levels before supplementation, using the nursing process to question unsafe orders. Prioritization follows DKA protocols that withhold potassium if above 5.2 mEq/L initially. A transferable strategy is to assess potassium levels serially in DKA, supplementing only when below 5.2 mEq/L after insulin starts.
  7. A 72-year-old man with type 2 diabetes is being treated for HHS. Vital signs: BP 100/64 mm Hg, HR 110/min, RR 18/min, T 37.9°C (100.2°F); glucose 760 mg/dL. Labs: serum osmolality 330 mOsm/kg (normal 275–295), pH 7.40 (normal 7.35–7.45), HCO3− 24 mEq/L (normal 22–26), serum ketones negative (normal negative). Which assessment finding indicates HHS rather than DKA in this patient?
    Answer: Serum ketones negative (normal negative) This question tests recognition and treatment of diabetic emergencies, distinguishing between hyperosmolar hyperglycemic state (HHS) and diabetic ketoacidosis (DKA) in a type 2 diabetes patient. The priority concern is identifying the absence of ketosis, which defines HHS and guides treatment without bicarbonate. Negative serum ketones indicate HHS rather than DKA, as HHS lacks significant ketone production despite hyperglycemia. Heart rate of 110/min reflects dehydration; blood glucose of 760 mg/dL is severe but common to both; temperature of 37.9°C suggests infection but not specificity. This uses clinical judgment to differentiate based on ketones and acidosis. Prioritization analyzes labs for syndrome identification. A transferable strategy is to check ketones in hyperglycemic crises to tailor therapy, using insulin cautiously in HHS.
  8. A 22-year-old woman with type 1 diabetes reports 24 hours of vomiting after a viral illness and now has polyuria, polydipsia, and abdominal pain. Vital signs: BP 92/58 mm Hg, HR 124/min, RR 28/min with deep respirations, T 37.8°C (100.0°F); bedside glucose 486 mg/dL. Labs: arterial pH 7.12 (normal 7.35–7.45), HCO3− 10 mEq/L (normal 22–26), anion gap 26 mEq/L (normal 8–12), serum ketones positive (normal negative). What is the nurse's PRIORITY intervention for this patient?
    Answer: Start large-bore IV access and begin isotonic fluid resuscitation with 0.9% sodium chloride This question tests recognition and treatment of diabetic emergencies, specifically diabetic ketoacidosis (DKA) in a patient with type 1 diabetes presenting with metabolic acidosis and dehydration. The priority concern is addressing severe dehydration and hypotension to restore perfusion and prevent organ failure. Starting large-bore IV access and beginning isotonic fluid resuscitation with 0.9% sodium chloride is the best choice because it rapidly corrects volume depletion, which is critical before initiating insulin therapy to avoid worsening hypotension. Administering sodium bicarbonate is less optimal as it is not routinely indicated unless pH is below 6.9; starting insulin without fluids risks circulatory collapse; and delegating neuro checks, while important, does not address the immediate life-threatening hypovolemia. This aligns with the ABC prioritization framework, focusing on circulation first, followed by the nursing process of assessment and intervention. Clinical judgment involves recognizing that fluid resuscitation precedes insulin in hypotensive DKA patients to stabilize hemodynamics. A transferable strategy is to always prioritize airway, breathing, and circulation in diabetic emergencies, ensuring volume status is addressed before correcting hyperglycemia or acidosis.
  9. A 21-year-old man with type 1 diabetes is treated for DKA. Current data: glucose 240 mg/dL, pH 7.32 (normal 7.35–7.45), HCO3− 18 mEq/L (normal 22–26), anion gap 14 mEq/L (normal 8–12), potassium 3.6 mEq/L (normal 3.5–5.0). Vital signs are stable. What is the nurse's PRIORITY intervention at this time?
    Answer: Add dextrose to IV fluids per protocol while continuing insulin to close the anion gap This question tests recognition and treatment of diabetic emergencies, managing resolving diabetic ketoacidosis (DKA) when glucose decreases but acidosis persists. The priority concern is closing the anion gap without causing hypoglycemia. Adding dextrose to IV fluids per protocol while continuing insulin is the best choice as it allows ongoing ketosis resolution while preventing low glucose. Stopping insulin risks rebound ketosis; transitioning to oral meds is premature; and delegating infusion adjustments exceeds UAP scope. This uses clinical judgment per DKA protocols to continue insulin until gap normalizes. Prioritization follows glucose and gap monitoring. A transferable strategy is to switch to dextrose-containing fluids when glucose falls below 250 mg/dL in DKA, maintaining insulin infusion.
  10. A 68-year-old woman with type 2 diabetes is admitted with confusion and dehydration after a urinary tract infection. Vital signs: BP 98/60 mm Hg, HR 118/min, RR 18/min, T 38.0°C (100.4°F); glucose 860 mg/dL. Labs: serum osmolality 332 mOsm/kg (normal 275–295), pH 7.38 (normal 7.35–7.45), HCO3− 24 mEq/L (normal 22–26), serum ketones negative (normal negative). Which lab value requires IMMEDIATE attention?
    Answer: Serum osmolality 332 mOsm/kg (normal 275–295) This question tests recognition and treatment of diabetic emergencies, specifically identifying critical lab values in hyperosmolar hyperglycemic state (HHS) for a type 2 diabetes patient with infection. The priority concern is addressing severe hyperosmolality leading to neurological changes and dehydration. Serum osmolality of 332 mOsm/kg requires immediate attention as it confirms HHS and drives osmotic diuresis, necessitating prompt fluid resuscitation. Arterial pH of 7.38, bicarbonate of 24 mEq/L, and negative ketones are normal and do not indicate acidosis or ketosis, which are absent in pure HHS. This uses clinical judgment by prioritizing labs that explain the patient's confusion and dehydration. The prioritization framework involves analyzing osmolality as the key differentiator in HHS. A transferable strategy is to check serum osmolality in non-ketotic hyperglycemia to guide rehydration therapy.
  11. A 67-year-old woman with type 2 diabetes is admitted for HHS after a week of cough and fever. Vital signs: BP 88/54 mm Hg, HR 128/min, RR 20/min, T 38.7°C (101.7°F); glucose 1,100 mg/dL. Labs: serum osmolality 360 mOsm/kg (normal 275–295), pH 7.42 (normal 7.35–7.45), HCO3− 25 mEq/L (normal 22–26), serum ketones negative (normal negative). Which lab value requires IMMEDIATE attention?
    Answer: Serum osmolality 360 mOsm/kg (normal 275–295) The correct priority in hyperosmolar hyperglycemic state (HHS) is the serum osmolality of 360 mOsm/kg — markedly above the normal ceiling of 295. Extreme hyperosmolality drives the altered mental status and seizure risk that make this an emergency, and it must be corrected slowly with isotonic fluids to prevent cerebral edema. The arterial pH of 7.42 is normal and, together with negative serum ketones and a normal anion gap, confirms this is HHS rather than diabetic ketoacidosis; there is no acidosis to treat. Negative serum ketones are expected in HHS because enough insulin remains to suppress ketogenesis, so this result requires no action. The bicarbonate of 25 mEq/L with a normal pH shows no metabolic acidosis is present and needs no correction. Each of these normal results is reassuring; only the osmolality is critically abnormal and demands immediate attention.
  12. A 76-year-old man with type 2 diabetes has had a cough and fever for 5 days and is now confused and very thirsty. Vital signs: blood glucose 980 mg/dL, blood pressure 88/54 mm Hg, heart rate 118/min, respiratory rate 20/min, temperature 38.3°C (100.9°F). Labs: serum osmolality 340 mOsm/kg (normal 275–295), arterial pH 7.36 (normal 7.35–7.45), bicarbonate 22 mEq/L (normal 22–26), serum ketones negative (normal negative). What is the nurse's PRIORITY intervention for this patient?
    Answer: Initiate aggressive isotonic intravenous fluid resuscitation and reassess perfusion This question tests recognition and treatment of diabetic emergencies, specifically hyperosmolar hyperglycemic state (HHS). The priority concern is addressing severe dehydration and hypotension, as indicated by blood pressure 88/54 mm Hg and extreme hyperglycemia (980 mg/dL) with high osmolality (340 mOsm/kg). Initiating aggressive isotonic intravenous fluid resuscitation and reassessing perfusion is the best choice because HHS patients have profound fluid deficits (often 8-12 liters) that must be corrected to prevent shock and organ failure. Starting insulin before fluids (A) can worsen hypotension; subcutaneous insulin (C) is inadequate for this emergency; neurologic assessments (D) delay critical treatment when the patient is hemodynamically compromised. The clinical judgment principle is treating life-threatening complications first - hypotension and dehydration take precedence over hyperglycemia. A transferable strategy is recognizing that HHS requires more aggressive fluid resuscitation than DKA due to greater fluid losses.
  13. A 25-year-old man with type 1 diabetes presents with DKA after missing insulin due to nausea. Vital signs: BP 98/60 mm Hg, HR 120/min, RR 32/min (deep), T 37.5°C (99.5°F); glucose 480 mg/dL. Labs: pH 7.15 (normal 7.35–7.45), HCO3− 10 mEq/L (normal 22–26), anion gap 27 mEq/L (normal 8–12), potassium 5.2 mEq/L (normal 3.5–5.0). The nurse should QUESTION which treatment order for this patient?
    Answer: Hold insulin therapy until the anion gap is within normal range This question tests recognition and treatment of diabetic emergencies, evaluating orders in diabetic ketoacidosis (DKA) for a type 1 diabetes patient. The priority concern is appropriately timing insulin to resolve ketosis and acidosis. The nurse should question holding insulin therapy until the anion gap is normal because insulin is needed to close the gap by stopping ketogenesis. Starting IV fluids and insulin is standard; cardiac monitoring addresses electrolyte risks. This applies clinical judgment per DKA protocols requiring insulin to normalize the gap. Prioritization uses the nursing process to implement evidence-based care. A transferable strategy is to continue insulin until anion gap closes, even if glucose normalizes, adding dextrose as needed.
  14. A 31-year-old woman with type 1 diabetes arrives with polyuria, polydipsia, and abdominal pain after missing insulin while treating a sinus infection. Vital signs: BP 96/60 mm Hg, HR 126/min, RR 32/min (deep), T 37.9°C (100.2°F); glucose 468 mg/dL. Labs: pH 7.14 (normal 7.35–7.45), HCO3− 11 mEq/L (normal 22–26), anion gap 24 mEq/L (normal 8–12), serum ketones positive (normal negative). Which lab value requires IMMEDIATE attention?
    Answer: Arterial pH 7.14 (normal 7.35–7.45) This question tests recognition and treatment of diabetic emergencies, emphasizing critical lab values in diabetic ketoacidosis (DKA) for a type 1 diabetes patient. The priority concern is addressing severe metabolic acidosis that can lead to coma or death. Arterial pH of 7.14 requires immediate attention as it indicates profound acidosis from ketoacid accumulation, necessitating urgent insulin and fluid therapy. Anion gap of 24 mEq/L and positive ketones support DKA but are secondary to pH; blood glucose of 468 mg/dL is expected but less immediately life-threatening. This applies clinical judgment by prioritizing pH as a marker of acidosis severity. The prioritization framework uses the nursing process to analyze labs for imminent threats. A transferable strategy is to monitor pH and bicarbonate in suspected DKA to guide aggressive treatment.
  15. A 28-year-old woman with type 1 diabetes is diagnosed with DKA after missing insulin during a urinary tract infection. Vital signs: BP 98/62 mm Hg, HR 120/min, RR 30/min (deep), T 38.0°C (100.4°F); glucose 470 mg/dL. Labs: pH 7.20 (normal 7.35–7.45), HCO3− 13 mEq/L (normal 22–26), anion gap 23 mEq/L (normal 8–12), serum ketones positive (normal negative). What is the nurse's PRIORITY intervention after initiating isotonic IV fluids?
    Answer: Start IV regular insulin infusion per protocol and monitor glucose and potassium closely This question tests recognition and treatment of diabetic emergencies, particularly next steps in diabetic ketoacidosis (DKA) management for a type 1 diabetes patient. The priority concern is correcting hyperglycemia and acidosis after initial fluid resuscitation. Starting IV regular insulin infusion per protocol and monitoring glucose and potassium closely is the best choice as it halts ketogenesis and lowers glucose safely. Administering subcutaneous long-acting insulin is inappropriate during acute DKA; encouraging oral intake is secondary; and delegating breath odor assessment is not priority or UAP-appropriate. This follows the nursing process, implementing evidence-based protocols. Clinical judgment prioritizes continuous insulin for precise control. A transferable strategy is to initiate IV insulin after fluids in DKA, with hourly glucose checks to prevent hypoglycemia.
  16. A 74-year-old woman with type 2 diabetes is admitted with HHS after a urinary tract infection. Vital signs: blood glucose 940 mg/dL, blood pressure 86/50 mm Hg, heart rate 122/min, respiratory rate 20/min. Labs: serum osmolality 346 mOsm/kg (normal 275–295), arterial pH 7.40 (normal 7.35–7.45), bicarbonate 25 mEq/L (normal 22–26), serum ketones negative (normal negative). Which assessment finding requires IMMEDIATE action during initial management?
    Answer: Urine output 15 mL/hr despite fluid administration This question tests recognition and treatment of diabetic emergencies, specifically identifying acute kidney injury in HHS. The priority concern is recognizing signs of organ dysfunction that require immediate intervention. Urine output of 15 mL/hr despite fluid administration requires immediate action because it indicates acute kidney injury or inadequate perfusion - normal urine output should be at least 30 mL/hr, and it should improve with fluid resuscitation. Dry mucosa and poor turgor (B) are expected with dehydration; persistent hyperglycemia initially (C) is expected; history of sugary drinks (D) explains worsening but doesn't require immediate action. The clinical judgment principle is monitoring end-organ perfusion - oliguria despite fluids suggests either severe dehydration or kidney injury requiring aggressive intervention. A transferable strategy is using urine output as a key indicator of adequate resuscitation in diabetic emergencies, expecting improvement within 1-2 hours of fluid initiation.
  17. A 32-year-old man with type 1 diabetes presents with abdominal pain and vomiting after missing insulin during a stomach virus. Vital signs: BP 98/58 mm Hg, HR 122/min, RR 32/min (deep), T 37.6°C (99.7°F); glucose 530 mg/dL. Labs: pH 7.08 (normal 7.35–7.45), HCO3− 7 mEq/L (normal 22–26), anion gap 32 mEq/L (normal 8–12), serum ketones positive (normal negative). The nurse should QUESTION which treatment order for this patient?
    Answer: Administer dextrose 50% IV now to prevent hypoglycemia This question tests the recognition and treatment of diabetic emergencies, specifically diabetic ketoacidosis (DKA) in a patient with type 1 diabetes presenting with hyperglycemia, metabolic acidosis, and ketosis. The priority concerns include addressing dehydration, correcting hyperglycemia and acidosis, and preventing complications like electrolyte imbalances. The nurse should question the order to administer dextrose 50% IV now to prevent hypoglycemia because the patient's current blood glucose is markedly elevated at 530 mg/dL, and dextrose is typically added later when glucose levels approach 200-250 mg/dL during insulin therapy. Starting 0.9% sodium chloride IV bolus is appropriate for initial fluid resuscitation in dehydration; beginning IV regular insulin infusion is essential to halt ketogenesis and lower glucose after fluids are started; and monitoring serum electrolytes, anion gap, and glucose frequently is crucial for guiding therapy and detecting complications like hypokalemia. This scenario applies the ABC prioritization framework (airway, breathing, circulation) by first ensuring circulatory stability through fluids, followed by insulin and monitoring. It also incorporates clinical judgment principles from the NCSBN model, emphasizing analysis of cues like vital signs and labs to prioritize interventions. A transferable strategy for recognizing and treating diabetic emergencies is to assess for the triad of hyperglycemia, acidosis, and ketosis in DKA, initiate fluids and insulin promptly, and monitor closely to adjust therapy based on trending lab values.
  18. A 23-year-old man with type 1 diabetes presents with polyuria, polydipsia, and abdominal pain. Vital signs: BP 100/60 mm Hg, HR 118/min, RR 28/min (deep), T 37.7°C (99.9°F); glucose 498 mg/dL. Labs: pH 7.22 (normal 7.35–7.45), HCO3− 14 mEq/L (normal 22–26), anion gap 21 mEq/L (normal 8–12), serum ketones positive (normal negative). Which lab value requires IMMEDIATE attention?
    Answer: Bicarbonate 14 mEq/L (normal 22–26) This question tests recognition and treatment of diabetic emergencies, emphasizing critical lab values in diabetic ketoacidosis (DKA) for a type 1 diabetes patient. The priority concern is addressing metabolic acidosis that impairs cellular function and can lead to shock. Bicarbonate of 14 mEq/L requires immediate attention as it indicates severe acidosis, prompting urgent insulin and fluid therapy to restore acid-base balance. Blood glucose of 498 mg/dL, positive ketones, and anion gap of 21 mEq/L are consistent with DKA but secondary to the bicarbonate depletion. This applies clinical judgment by prioritizing bicarbonate as a direct measure of acidosis. The prioritization framework uses lab analysis to identify threats to homeostasis. A transferable strategy is to correlate low bicarbonate with pH in DKA for timely intervention.
  19. A 24-year-old woman with type 1 diabetes arrives with polyuria, polydipsia, and abdominal pain after a recent urinary tract infection. Vital signs: blood glucose 560 mg/dL, blood pressure 94/62 mm Hg, heart rate 120/min, respiratory rate 32/min with deep rapid respirations. Labs: arterial pH 7.10 (normal 7.35–7.45), bicarbonate 9 mEq/L (normal 22–26), anion gap 28 mEq/L (normal 8–12), serum ketones positive (normal negative). Which assessment finding indicates diabetic ketoacidosis (DKA) in this patient?
    Answer: Deep, rapid respirations with a low bicarbonate level This question tests recognition and treatment of diabetic emergencies, specifically identifying diagnostic criteria for DKA. The priority concern is recognizing the pathophysiologic hallmarks that distinguish DKA from other hyperglycemic states. Deep, rapid respirations (Kussmaul breathing) with a low bicarbonate level (9 mEq/L) indicates DKA because this compensatory respiratory pattern occurs in response to severe metabolic acidosis. Normal osmolality (A) doesn't indicate DKA; hyperglycemia without ketones (C) suggests HHS; confusion with normal pH (D) could indicate HHS but not DKA. The clinical judgment principle is recognizing the triad of DKA: hyperglycemia, ketosis, and metabolic acidosis with compensatory hyperventilation. A transferable strategy for recognizing DKA is to look for Kussmaul respirations combined with laboratory evidence of acidosis (low pH, low bicarbonate) and positive ketones.
  20. A 79-year-old woman with type 2 diabetes is admitted for hyperosmolar hyperglycemic state (HHS) after pneumonia. Vital signs: blood glucose 860 mg/dL, blood pressure 90/56 mm Hg, heart rate 110/min, respiratory rate 18/min. Labs: serum osmolality 332 mOsm/kg (normal 275–295), arterial pH 7.38 (normal 7.35–7.45), bicarbonate 24 mEq/L (normal 22–26), serum ketones negative (normal negative). The provider prescribes several orders. The nurse should QUESTION which treatment order for this patient?
    Answer: Administer furosemide intravenously now for dehydration-related oliguria This question tests recognition and treatment of diabetic emergencies, specifically identifying inappropriate orders in HHS management. The priority concern is preventing iatrogenic complications during treatment of severe dehydration. The nurse should question administering furosemide intravenously for oliguria because diuretics are contraindicated in HHS - these patients have profound volume depletion, and oliguria is due to dehydration, not fluid overload. Starting with isotonic fluids (A) is appropriate for initial resuscitation; insulin after fluids (B) follows correct sequencing; frequent monitoring (D) is essential during treatment. The clinical judgment principle is recognizing contraindications - diuretics worsen dehydration in hyperglycemic emergencies. A transferable strategy is understanding that oliguria in diabetic emergencies indicates severe dehydration requiring fluid replacement, never diuresis.

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