Fluids and electrolytes Flashcards
A nurse is caring for a patient with diabetic ketoacidosis (DKA). The provider has ordered IV insulin therapy. Which of the following lab values would require the nurse to hold the insulin infusion and take further action?
A) Blood glucose of 17 mmol/L
B) Serum potassium of 5.4 mEq/L
C) Serum potassium of 3.0 mEq/L
D) Presence of ketones in the urine
Rationale:
A) Blood glucose of 17 mmol/L – Incorrect
Insulin therapy is still needed to lower blood glucose and correct acidosis. This value alone does not indicate that insulin should be held.
B) Serum potassium of 5.4 mEq/L – Incorrect
This is slightly elevated but does not require holding insulin. Potassium should be monitored, but insulin can still be given.
C) Serum potassium of 3.0 mEq/L – Correct
Insulin pushes potassium into cells, which can further lower potassium levels and cause dangerous hypokalemia. If K+ is below 3.3 mEq/L, insulin must be held until potassium is replaced.
D) Presence of ketones in the urine – Incorrect
Ketones are expected in DKA and confirm the diagnosis. Insulin is essential to stop fat breakdown and clear ketones from the system.
A patient with DKA is receiving IV insulin therapy. When should the nurse initiate glucose administration?
A) When blood glucose is >20 mmol/L
B) When blood glucose is <15 mmol/L
C) When blood glucose is between 18-20 mmol/L
D) When blood glucose is >34 mmol/L
Correct Answer: B) When blood glucose is <15 mmol/L
Rationale: Once blood glucose drops below 15 mmol/L, dextrose (D5W) should be added to prevent hypoglycemia while continuing insulin therapy.
Which patient is at the highest risk of developing Hyperosmolar Hyperglycemic State (HHS)?
A) A 25-year-old with Type 1 DM who missed an insulin dose
B) A 70-year-old with Type 2 DM who is dehydrated and has a history of dementia
C) A 10-year-old with newly diagnosed Type 1 DM experiencing nausea and vomiting
D) A 50-year-old patient with chronic kidney disease on dialysis
Correct Answer: B) A 70-year-old with Type 2 DM who is dehydrated and has a history of dementia
Rationale: HHS is more common in older adults with Type 2 DM, especially those with dehydration, impaired thirst, or cognitive decline, which delays recognition and treatment.
A nurse is reviewing lab results for a patient with DKA. Which finding is expected?
A) Blood glucose 5 mmol/L
B) Serum osmolality 270 mOsm/L
C) Presence of ketones in the urine
D) Serum bicarbonate >24 mEq/L
Correct Answer: C) Presence of ketones in the urine
Rationale: DKA is characterized by ketosis, acidosis, and hyperglycemia. Ketones indicate fat breakdown due to insulin deficiency.
A nurse is caring for a patient with a serum potassium level of 2.9 mEq/L and DKA. What is the priority action?
A) Start IV insulin therapy
B) Give IV potassium replacement
C) Restrict potassium-rich foods
D) Administer sodium bicarbonate
Correct Answer: B) Give IV potassium replacement
Rationale: Potassium must be corrected before starting insulin because insulin shifts potassium into cells, worsening hypokalemia, which can lead to arrhythmias.
Which assessment finding requires immediate intervention in a patient with DKA?
A) Blood glucose of 20 mmol/L
B) Kussmaul’s respirations and acetone breath
C) Serum potassium of 2.8 mEq/L
D) BP of 110/70 mmHg
Correct Answer: C) Serum potassium of 2.8 mEq/L
Rationale: Severe hypokalemia (<3.3 mEq/L) can cause life-threatening arrhythmias and must be corrected before insulin is given
What is the primary cause of metabolic acidosis in DKA?
A) Excessive bicarbonate loss
B) Accumulation of ketone bodies
C) Dehydration and electrolyte imbalance
D) Increased lactate production
Correct Answer: B) Accumulation of ketone bodies
Rationale: Fat metabolism leads to ketone production, which causes metabolic acidosis in DKA.
The nurse understands that the 5 I’s can precipitate DKA. Which of the following is NOT one of the 5 I’s?
A) Infection
B) Indiscretion (poor management)
C) Immobility
D) Insulin (lack of)
Correct Answer: C) Immobility
Rationale: The 5 I’s are infection, infarction, infant (childhood onset), indiscretion (not managing diabetes properly), and insulin (lack of).
Which of the following is a major difference between HHS and DKA?
A) HHS has no significant ketosis or acidosis
B) DKA occurs only in Type 2 diabetes
C) HHS is characterized by severe metabolic acidosis
D) DKA has higher glucose levels than HHS
Correct Answer: A) HHS has no significant ketosis or acidosis
Rationale: HHS involves extreme hyperglycemia and dehydration but does not cause ketosis or metabolic acidosis
A nurse is teaching a patient about the 15/15 rule for hypoglycemia. What is the correct approach?
A) Eat 15g of carbs and recheck BG in 15 minutes
B) Eat 30g of carbs and wait 30 minutes
C) Administer IV dextrose immediately
D) Take insulin to correct glucose levels
Correct Answer: A) Eat 15g of carbs and recheck BG in 15 minutes
Rationale: The 15/15 rule helps gradually raise blood sugar and prevent rebound hypoglycemia.
Which hypoglycemia treatment is best for a patient who is unconscious?
A) 15g oral glucose
B) IM or IV glucagon
C) Fruit juice
D) Wait for the patient to wake up
Correct Answer: B) IM or IV glucagon
Rationale: Unconscious patients cannot safely take oral glucose. IM or IV glucagon is the preferred treatment.
A patient with DKA is receiving IV fluids. Which solution is appropriate for initial rehydration?
A) D5W
B) 0.9% Normal Saline (NS)
C) 3% Hypertonic Saline
D) 0.45% Hypotonic Saline
Correct Answer: B) 0.9% Normal Saline (NS)
Rationale: NS is the first-line fluid for DKA to correct dehydration.
Which electrolyte imbalance is common in both DKA and HHS?
A) Hypokalemia
B) Hypercalcemia
C) Hypophosphatemia
D) Hypermagnesemia
Correct Answer: A) Hypokalemia
Rationale: Insulin therapy can cause potassium to shift into cells, leading to hypokalemia.
A patient in HHS presents with severe neurological symptoms. Which finding is most concerning?
A) Somnolence
B) Blood glucose of 36 mmol/L
C) Seizures
D) Polyuria
Correct Answer: C) Seizures
Rationale: Severe hyperosmolality in HHS can lead to coma or seizures, requiring immediate intervention.
A nurse is evaluating a patient’s response to DKA treatment. Which finding indicates improvement?
A) Presence of ketones in urine
B) Blood glucose of 28 mmol/L
C) Normal anion gap and pH >7.3
D) Bicarbonate level of 12 mEq/L
Correct Answer: C) Normal anion gap and pH >7.3
Rationale: Resolution of DKA is indicated by normal pH and closure of the anion gap.
What is a priority nursing diagnosis for a patient with DKA?
A) Ineffective Breathing Pattern
B) Fluid Volume Deficit
C) Risk for Aspiration
D) Risk for Hyperthermia
Correct Answer: B) Fluid Volume Deficit
Rationale: Severe dehydration is a primary concern in DKA, requiring aggressive fluid replacement.
A patient with newly diagnosed type 1 diabetes is admitted with diabetic ketoacidosis (DKA). The nurse understands that which of the following is the priority intervention?
A) Administering IV potassium before starting insulin
B) Initiating an insulin drip immediately
C) Administering isotonic fluids to correct dehydration
D) Encouraging the patient to increase oral fluid intake
Answer: C) Administering isotonic fluids to correct dehydration.
Rationale:
Fluid replacement is the first priority in DKA to correct dehydration and restore circulatory volume. Insulin therapy is initiated after potassium levels are checked, as insulin can cause hypokalemia. Oral fluid intake is insufficient in severe dehydration.
A patient with type 2 diabetes presents with confusion and a blood glucose level of 38 mmol/L. Which assessment finding would indicate that the patient has hyperosmolar hyperglycemic state (HHS) rather than DKA?
A) Fruity breath odor
B) Kussmaul’s respirations
C) Absence of ketones in the urine
D) Blood glucose level of 15 mmol/L
Answer: C) Absence of ketones in the urine.
Rationale:
HHS is characterized by extreme hyperglycemia, severe dehydration, and an absence of ketosis. Fruity breath odor and Kussmaul’s respirations are seen in DKA due to ketosis and metabolic acidosis.
A nurse is preparing to administer IV insulin to a patient in DKA. The patient’s potassium level is 3.0 mEq/L. What should the nurse do next?
A) Administer the insulin as prescribed
B) Give an IV bolus of dextrose before insulin
C) Administer potassium replacement before starting insulin
D) Recheck the potassium level in 6 hours
Answer: C) Administer potassium replacement before starting insulin.
Rationale:
Insulin drives potassium into cells, potentially worsening hypokalemia, which can cause life-threatening cardiac arrhythmias. Potassium should be corrected before initiating insulin therapy.
A nurse is teaching a patient with diabetes about recognizing signs of hypoglycemia. Which symptom should the patient report immediately?
A) Increased thirst and frequent urination
B) Nausea and vomiting
C) Diaphoresis and confusion
D) Flushed skin and deep respirations
Answer: C) Diaphoresis and confusion.
Rationale:
Hypoglycemia causes symptoms due to activation of the sympathetic nervous system (e.g., diaphoresis, confusion, tremors). Increased thirst and urination are signs of hyperglycemia.
A patient with HHS has a blood glucose level of 40 mmol/L and is receiving normal saline. Which additional order should the nurse anticipate?
A) IV dextrose once blood glucose reaches 14 mmol/L
B) Administration of sodium bicarbonate
C) Immediate IV push of rapid-acting insulin
D) Fluid restriction to prevent overload
Answer: A) IV dextrose once blood glucose reaches 14 mmol/L.
Rationale:
IV dextrose is added when blood glucose drops to 14 mmol/L to prevent hypoglycemia while continuing insulin therapy. Sodium bicarbonate is not routinely given. Insulin should be given as an infusion, not a bolus.
A nurse is assessing a patient with suspected DKA. Which finding supports this diagnosis?
A) Slow, shallow respirations
B) Serum bicarbonate level of 24 mEq/L
C) Blood glucose of 8 mmol/L
D) pH of 7.25 with ketonuria
Answer: D) pH of 7.25 with ketonuria.
Rationale:
DKA is characterized by metabolic acidosis (low pH), ketonuria, and hyperglycemia. Bicarbonate levels would be low, not normal.
A patient with hypoglycemia is given 15g of carbohydrates per the 15/15 rule. What should the nurse do next?
A) Administer another 15g of carbohydrates immediately
B) Check blood glucose in 15 minutes
C) Give an IV bolus of glucose
D) Notify the provider
Answer: B) Check blood glucose in 15 minutes.
Rationale:
After administering carbohydrates, blood glucose should be reassessed in 15 minutes. If still low, another dose may be needed.
A patient receiving IV insulin for DKA reports dizziness and palpitations. What is the priority action?
A) Check the patient’s blood glucose level
B) Increase the insulin infusion rate
C) Administer 50% dextrose IV
D) Stop the IV fluids
Answer: A) Check the patient’s blood glucose level.
Rationale:
Dizziness and palpitations may indicate hypoglycemia due to insulin therapy. Blood glucose should be checked immediately.
Which of the following is the best indicator of fluid balance in a patient with DKA?
A) Blood glucose level
B) Serum potassium level
C) Daily weight
D) Skin turgor
Answer: C) Daily weight.
Rationale:
Daily weight is the most accurate measure of fluid balance.
Which IV fluid should the nurse anticipate administering first in HHS?
A) 3% saline
B) D5W
C) 0.9% normal saline
D) 0.45% saline
Answer: C) 0.9% normal saline.
Rationale:
Fluid resuscitation with isotonic saline is the first step in treating HHS.
A patient with DKA has a serum potassium of 5.5 mEq/L. What is the appropriate intervention?
A) Start IV potassium replacement
B) Hold potassium replacement and monitor
C) Administer sodium bicarbonate
D) Restrict oral fluids
Answer: B) Hold potassium replacement and monitor.
Rationale:
Potassium replacement is held if levels are >5.2 mEq/L and monitored closely.
A patient in HHS is experiencing aphasia and hemiparesis. What is the priority intervention?
A) Perform a neurological assessment
B) Obtain a blood glucose level
C) Administer IV insulin
D) Check for ketones in urine
Answer: B) Obtain a blood glucose level.
Rationale:
Neurological symptoms in HHS are due to severe hyperglycemia, and immediate glucose monitoring is needed.
Which of the following is most concerning in a patient receiving insulin for DKA?
A) Blood glucose of 14 mmol/L
B) Potassium of 3.2 mEq/L
C) pH of 7.35
D) Resolution of ketonuria
Answer: B) Potassium of 3.2 mEq/L.
Rationale:
Hypokalemia is a critical concern in DKA treatment and must be corrected before continuing insulin therapy.
A patient in DKA has been receiving IV insulin. Their blood glucose is now 15 mmol/L. What is the next priority intervention?
A) Discontinue the insulin infusion
B) Administer IV dextrose while continuing insulin
C) Switch to subcutaneous insulin immediately
D) Decrease IV fluid rate to prevent overload
Answer: B) Administer IV dextrose while continuing insulin.
Rationale:
Once blood glucose drops to 15 mmol/L, IV dextrose is added to prevent hypoglycemia while insulin therapy continues to correct ketosis. Stopping insulin too soon may worsen acidosis.
A nurse is reviewing the lab results of a patient with HHS. Which finding is most concerning?
A) Blood glucose of 35 mmol/L
B) Serum osmolality of 340 mOsm/L
C) Serum sodium of 125 mEq/L
D) Potassium of 5.0 mEq/L
Answer: C) Serum sodium of 125 mEq/L.
Rationale:
Hyponatremia (<135 mEq/L) is concerning as it may indicate severe fluid imbalance and neurological compromise. While hyperglycemia and increased osmolality are expected in HHS, critical sodium imbalances require urgent intervention.
A patient with a history of diabetes is found unresponsive with cold, clammy skin. What is the priority nursing action?
A) Administer IV 50% dextrose
B) Check the patient’s blood glucose
C) Call the healthcare provider
D) Position the patient on their side
Answer: B) Check the patient’s blood glucose.
Rationale:
Unresponsiveness and cold, clammy skin suggest severe hypoglycemia. Blood glucose should be assessed first to confirm, followed by IV dextrose administration if low
A patient with hypoglycemia does not respond to oral carbohydrates. What should the nurse do next?
A) Administer 1 mg glucagon IM
B) Start an IV insulin infusion
C) Restrict fluids to prevent overload
D) Monitor blood glucose every hour
Answer: A) Administer 1 mg glucagon IM.
Rationale:
If oral carbohydrates are ineffective, glucagon IM is used to stimulate hepatic glucose release. Insulin is contraindicated.
A patient with DKA has Kussmaul’s respirations. The nurse understands that this compensatory mechanism is due to:
A) Respiratory alkalosis
B) Metabolic acidosis
C) Hyperosmolarity
D) Hypoglycemia
Answer: B) Metabolic acidosis.
Rationale:
Kussmaul’s respirations occur due to metabolic acidosis as the body attempts to “blow off” excess CO₂.
A nurse is caring for a patient with end-stage renal disease (ESRD) and diabetes. The nurse anticipates which change in insulin needs?
A) Increased insulin needs
B) No change in insulin requirements
C) Decreased insulin needs
D) Switch to oral antidiabetics
Answer: C) Decreased insulin needs.
Rationale:
In ESRD, insulin clearance is reduced, leading to increased risk of hypoglycemia. Insulin requirements are often decreased.
A patient receiving IV fluids for HHS suddenly develops crackles in the lungs and dyspnea. What is the priority action?
A) Increase the IV fluid rate
B) Stop IV fluids and assess the patient
C) Encourage deep breathing exercises
D) Administer an IV diuretic
Answer: B) Stop IV fluids and assess the patient.
Rationale:
Crackles and dyspnea suggest fluid overload, a risk in HHS treatment. The nurse should stop fluids and assess for worsening pulmonary edema.
