NCLEX-RN Practice Test 14

0920 (Emergency Department): Client, age 21, brought in by a roommate. States, "I skipped my long-acting insulin the last two nights because I couldn't eat." Reports nausea, vomiting and diffuse abdominal pain for 2 days, intense thirst and frequent urination for 3 days. Client is drowsy and slow to answer questions but is oriented to person, place and time. Respirations deep and rapid, with a fruity odor on the breath. Lungs clear to auscultation bilaterally. Oral mucosa dry; skin warm and dry with poor turgor; capillary refill 4 seconds. Pupils equal, round and reactive to light. Abdomen soft, diffusely tender; bowel sounds hypoactive. Point-of-care glucose 548 mg/dL. Two peripheral IV catheters (18-gauge) inserted. Roommate remains at the bedside and has phoned the client's parents.

History and Physical (0930). Chief complaint: vomiting and abdominal pain × 2 days. History of present illness: sore throat, muscle aches and nonproductive cough × 5 days; two classmates recently had influenza. Stopped insulin glargine 2 nights ago when unable to eat; has not checked glucose since yesterday morning. Past medical history: type 1 diabetes mellitus diagnosed at age 11; one prior DKA admission at age 16. Home medications: insulin glargine 20 units subcutaneously at bedtime; insulin lispro subcutaneously with meals (1 unit per 12 g carbohydrate) plus correction scale. Allergies: no known drug allergies. Social: full-time college student, lives with a roommate; drinks alcohol "a few times a month"; denies tobacco or drug use. Weight 58 kg (usual 61 kg). Assessment: diabetic ketoacidosis, likely precipitated by viral illness and omitted basal insulin.

Orders (0940): Admit to intensive care unit; diagnosis diabetic ketoacidosis. NPO except ice chips. 0.9% sodium chloride 1,000 mL IV over 1 hour, then 0.9% sodium chloride at 250 mL/h. Regular insulin 100 units in 100 mL 0.9% sodium chloride: continuous IV infusion at 0.1 units/kg/h (5.8 units/h) — start only after the serum potassium result is reviewed; hold insulin and notify provider if potassium is less than 3.5 mEq/L. Potassium protocol: potassium greater than 5.0 mEq/L — no potassium in IV fluid; 3.5–5.0 mEq/L — add potassium chloride 20 mEq to each liter of IV fluid if urine output is at least 0.5 mL/kg/h; less than 3.5 mEq/L — hold insulin, give potassium chloride 10 mEq/h IV and notify provider. When glucose is less than 250 mg/dL: change IV fluid to 5% dextrose in 0.45% sodium chloride at 150 mL/h and decrease insulin to 0.05 units/kg/h (2.9 units/h); maintain glucose 150–200 mg/dL. Do not stop the insulin infusion until the anion gap is closed and provider orders the transition to subcutaneous insulin. Capillary glucose every 1 hour. Basic metabolic panel every 2 hours; venous blood gas and beta-hydroxybutyrate every 4 hours. Continuous cardiac monitoring. Strict intake and output. Ondansetron 4 mg IV every 6 hours PRN nausea. Respiratory viral PCR panel (influenza A/B, COVID-19).