24. A client with a history of type 1 diabetes has not been eating or taking insulin for 3 days because of "feeling poorly." The client is confused, respirations are 32, and breath odor is fruity. The serum glucose is 620 mg/dL. A nurse should know that the correct action for this client is:
. Rapid rehydration with NS at 1 L/hr per order.
. Regular insulin IV 5 units/hr in D5NS per order.
. Begin 40% O2 per order.
. Begin infusion of sodium bicarbonate per order.
Test-Taking Tip
Recognize the characteristic signs and symptoms of diabetic ketoacidosis.
Content Area: Adult Health, Endocrine; Integrated Process: Nursing Process, Analysis; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Medical Emergencies
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Answer 1 is incorrect because hydration alone is not the correct action. An insulin drip is needed. Answer 2 is correct because the client needs insulin and fluids to correct the hyperglycemia (serum glucose of 620 mg/dL) and dehydration that occurs with diabetic ketoacidosis (DKA). Answer 3 is incorrect because the rapid respirations are compensation for the metabolic acidosis (Kussmaul's breathing). The respirations will slow as the diabetic ketoacidosis is corrected. Answer 4 is incorrect because the first action is an insulin drip and hydration. IV bicarbonate may be given for severe acidosis, but the pH is not known here.