A client is diagnosed with diabetic ketoacidosis (DKA). The client reports frequent urination, thirst, and weakness. The nurse assesses a temperature of 102.4 F (39.1 C), fruity breath, deep labored respirations with a rate of 30/min, and dry mucous membranes. What is the priority nursing diagnosis (ND) at this time?

Question

Quizplus · Accepted Answer

DKA is a life-threatening emergency caused by a relative or absolute insulin deficiency. The condition is characterized by hyperglycemia, ketosis, metabolic acidosis, and dehydration. The most likely contributing factors in this client include stress associated with illness and infection (elevated temperature) and inadequate insulin dosage and self-management. Deficient fluid volume related to osmotic diuresis secondary to hyperglycemia as evidenced by dry mucous membranes and client report of frequent urination, thirst, and weakness is the priority ND. Hyperglycemia leads to osmotic diuresis, dehydration, electrolyte imbalance, and possible hypovolemic shock and renal failure. Therefore, this condition requires rapid correction through the infusion of isotonic intravenous fluids and poses the greatest risk to the client's survival (Option A). (Option B) When the supply of insulin is insufficient and glucose cannot be metabolized for energy, the body breaks down fat stores leading to ketosis (fruity breath) and metabolic acidosis. However, it does not pose the greatest risk to survival and is not the priority ND. (Option C) Tachypnea and deep labored respirations (ie, Kussmaul) are the body's attempt to eliminate excess acid (pCO₂) through hyperventilation and normalize the pH. However, it does not pose the greatest risk to survival and is not the priority ND. (Option D) Ineffective health maintenance related to inability to manage a condition during illness (evidenced by DKA development in this client) is an appropriate ND. However, it does not pose the greatest risk to survival at this time and is not the priority ND. Educational objective: Hyperglycemia associated with DKA leads to osmotic diuresis, dehydration, electrolyte imbalance, and possible hypovolemic shock and renal failure. Deficient fluid volume related to osmotic diuresis is an appropriate ND for a client with DKA.

A Client Is Diagnosed with Diabetic Ketoacidosis (DKA)