NCLEX Question of the Day – Friday, February 27, 2026

Today’s question targets priority-setting in a metabolic emergency. In real nursing, doing the right step first in diabetic ketoacidosis (DKA) prevents shock, arrhythmias, and cerebral edema. You must know the sequence, not just the treatments.

Clinical Scenario

A 22-year-old college student arrives to the ED with 2 days of vomiting, polyuria, and abdominal pain. History: type 1 diabetes, inconsistent insulin use during exams. He is drowsy and answers slowly. Vitals: HR 124, BP 88/54, RR 30 with deep Kussmaul breaths, SpO2 97% on room air, temp 37.9 C. Exam shows dry mucous membranes and poor skin turgor.

Labs: Glucose 468 mg/dL, Na 130 mEq/L, K 5.6 mEq/L, HCO3 9 mEq/L, anion gap 24. Venous pH 7.12. Urine positive for large ketones. The provider has entered initial DKA orders.

The Question

Which order should the nurse implement first?

Answer Choices

1. A. Begin 0.9% normal saline bolus at 1,000 mL over 1 hour
2. B. Start IV regular insulin infusion at 0.1 unit/kg/hr
3. C. Administer potassium chloride 40 mEq IV over 1 hour
4. D. Administer sodium bicarbonate 50 mEq IV push

Correct Answer

A. Begin 0.9% normal saline bolus at 1,000 mL over 1 hour

Detailed Rationale

This patient has classic DKA: hyperglycemia, high anion gap metabolic acidosis, ketonuria, and Kussmaul respirations. The shock risk is real. Severe hyperglycemia causes osmotic diuresis, leading to major fluid loss and hypotension. The most immediate threat is poor perfusion.

ABCs guide the sequence. Airway is patent. Breathing is labored but compensatory. Circulation is unstable (BP 88/54, tachycardia, dry mucosa). Therefore, restore intravascular volume first with isotonic fluid. A 0.9% normal saline bolus improves preload, perfuses kidneys, and helps clear ketones. Fluids alone also lower glucose by dilution and improved renal excretion.

Insulin is essential but comes after initial fluids. Starting insulin before resuscitation can worsen hypotension because insulin drives water and potassium back into cells, lowering intravascular volume and serum potassium. With a K of 5.6, total body potassium is actually depleted, but serum appears high due to acidosis and shift out of cells. Begin insulin once perfusion is improving and labs/ECG are being monitored.

Do not give potassium right now. Despite total body deficit, the measured K is high. Giving potassium with a serum K of 5.6 and unknown urine output risks dangerous hyperkalemia. Replace potassium when K trends to normal or low and urine output is adequate (typically ≥ 30 mL/hr). Continuous ECG monitoring helps catch peaked T waves or conduction delays.

Avoid sodium bicarbonate unless pH is ≤ 6.9 or there is life-threatening hyperkalemia with instability. Bicarbonate can worsen intracellular acidosis in the brain, drop potassium rapidly, and increase sodium load. In this case, pH 7.12 does not meet criteria.

What to assess and monitor now:

• Vital signs every 15 minutes during the first bolus; watch for improving BP and HR.
• Lung sounds for fluid overload (crackles) as boluses continue, especially if any cardiac or renal risk emerges.
• Strict I&O; aim for urine output ≥ 30 mL/hr before potassium replacement.
• Point-of-care glucose hourly; basic metabolic panel every 2–4 hours to track potassium, bicarbonate, and anion gap closure.
• Neurologic status; avoid dropping glucose faster than about 50–75 mg/dL/hr to reduce cerebral edema risk. When glucose approaches 200–250 mg/dL, switch to dextrose-containing fluids while insulin continues to clear ketones.

Why the Other Options Are Wrong

• B. Start IV regular insulin infusion – Insulin before fluids can worsen hypotension and precipitate a sharp potassium drop, leading to arrhythmias. Volume first, then insulin.
• C. Administer potassium chloride – Serum K is 5.6 mEq/L. Immediate replacement risks hyperkalemia and cardiac arrest. Replace when K is normal/low and there is adequate urine output.
• D. Administer sodium bicarbonate – Not indicated at pH 7.12. It can cause paradoxical CNS acidosis and rapid potassium shifts. Reserve for pH ≤ 6.9 or select unstable scenarios.

Key Takeaways

• In DKA, treat circulation first: isotonic fluid bolus improves perfusion and starts glucose reduction.
• Begin insulin after initial fluids; it lowers glucose and closes the anion gap but can drop potassium.
• Potassium replacement depends on current K and urine output; do not give if K is high.
• Avoid bicarbonate unless pH ≤ 6.9; correct the acidosis by clearing ketones with insulin and fluids.

• Mini-checklist on shift:
• Start 0.9% NS bolus; reassess BP, HR, mental status.
• Place on cardiac monitor; obtain repeat BMP and bedside glucose.
• When perfusion improves, start IV insulin; plan to add dextrose when glucose 200–250 mg/dL.
• Replace potassium as indicated and only with adequate urine output; monitor ECG continuously.

Quick Practice Extension

• After 2 liters of NS, BP rises to 104/64, glucose falls to 360, and K is now 4.3 with urine output 40 mL/hr. What are your next two adjustments to fluids and electrolytes?
• The patient’s glucose drops from 300 to 180 mg/dL in 30 minutes after starting insulin. What specific fluid and insulin rate changes help prevent cerebral edema while continuing to clear ketones?

G S Sachin

I am a Registered Pharmacist under the Pharmacy Act, 1948, and the founder of PharmacyFreak.com. I hold a Bachelor of Pharmacy degree from Rungta College of Pharmaceutical Science and Research. With a strong academic foundation and practical knowledge, I am committed to providing accurate, easy-to-understand content to support pharmacy students and professionals. My aim is to make complex pharmaceutical concepts accessible and useful for real-world application.

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