The nurse is caring for a client with diabetic ketoacidosis (DKA) receiving a continuous regular insulin infusion.
Which client assessment may indicate that the client is experiencing a complication?
The nurse is caring for a client with diabetic ketoacidosis (DKA) receiving a continuous regular insulin infusion.
Which client assessment may indicate that the client is experiencing a complication?
A. flushed, dry skin
[11%]
B. nausea and vomiting
[17%]
C. orthostatic hypotension
[16%]
D. irritability
[56%]
Statistics
Subject/Lesson
Subject
Critical Care
Lesson
Critical Care Concepts
Client Need
Test Plan
Reduction of Risk Potential
Related Topic
Potential for Complications of Diagnostic Tests/Treatments/Procedures
Item Type
Item Type
Analysis
Explanation
Choice D is correct. The most significant complications associated with a regular insulin infusion are hypoglycemia and hypokalemia. Irritability is a strong indicator that the client may be experiencing hypoglycemia. Other symptoms of hypoglycemia include pallor, diaphoresis, increased hunger, confusion, and dizziness. Hypoglycemia is a blood glucose level less than 70 mg/dL (3.9 mmol/L). The nurse must regularly assess the client for these life-threatening complications.
Choice A is incorrect. Flushed, dry skin is a manifestation associated with hyperglycemia. Hyperglycemia is a finding related to diabetic ketoacidosis. This finding does not indicate that the client is experiencing a complication.
Choice B is incorrect. Nausea and vomiting are common manifestations associated with diabetic ketoacidosis. This is because the individual likely experiences gastroparesis from the significantly high blood glucose.
Choice C is incorrect. Orthostatic hypotension is a manifestation associated with hyperglycemia. Individuals with hyperglycemia become dehydrated because of the polyuria. Hyperglycemia is a finding related to diabetic ketoacidosis. This finding does not indicate that the client is experiencing a complication.
Related Videos
2 Key Topics
Diabetes Mellitus Type I
19.10 Diabetes Mellitus & Glycemic Control
Additional Info
✓ For a client with DKA, the immediate need should focus on restoring the depleted fluid volume caused by hyperglycemia (polyuria).
✓ Additionally, regular insulin intravenously is prescribed to correct the acidosis and hyperglycemia.
✓ During the infusion of regular insulin, the client should be monitored for hypoglycemia and hypokalemia.
