NCLEX-RN practice › Physiological Adaptation
NCLEX question: when to start basal insulin as DKA resolves
Physiological Adaptation · Multiple choice · Clinical judgment step: Take action
Client record
Laboratory results
| Time | 0200 | 0800 | 1400 |
|---|---|---|---|
| Glucose (mg/dL) | 412 | 236 | 182 |
| pH | 7.12 | 7.26 | 7.34 |
| Bicarbonate (mEq/L) | 9 | 15 | 19 |
| Anion gap (mEq/L) | 28 | 18 | 11 |
| Potassium (mEq/L) | 5.6 | 4.1 | 4.0 |
Infusions
- Regular insulin
- 5 units/hr
- Dextrose 5% in 0.45% sodium chloride
- 150 mL/hr
A client admitted with diabetic ketoacidosis has been on a continuous IV regular insulin infusion for 18 hours. The client is alert, asking to eat, and the provider has written a prescription for subcutaneous insulin glargine. Based on the client record, which action should the nurse take?
- A. Stop the insulin infusion, then give the insulin glargine 1 hour later
- B. Give the insulin glargine and continue the insulin infusion for 1 to 2 hours before stopping it
- C. Keep the insulin infusion running until the glucose is below 120 mg/dL
- D. Hold the insulin glargine until the potassium is above 5.0 mEq/L
Show the answer and rationales
Answer: B
DKA has resolved when the anion gap closes and pH and bicarbonate recover. Subcutaneous basal insulin is given 1 to 2 hours before the IV insulin is stopped to prevent rebound ketosis.
- A. Incorrect. Stopping the infusion before the basal insulin is working leaves the client with no insulin and risks rebound ketoacidosis.
- B. Correct. Correct. The acidosis has resolved (gap closed, pH and bicarbonate normalising) and the client can eat. Basal insulin must overlap the infusion for 1 to 2 hours because IV regular insulin is gone within minutes; stopping first lets ketosis return.
- C. Incorrect. The infusion end point in DKA is resolution of acidosis, not a normal glucose. Glucose is managed with dextrose while the gap closes.
- D. Incorrect. Potassium 4.0 is within the target range. Potassium below 3.3 is the level that requires holding insulin.
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