After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound.
Which action should the nurse take next?

Choice A rationale:

Starting an insulin drip at 0.1 u/kg/hr is a common treatment for diabetic ketoacidosis (DKA). The goal is to lower blood glucose levels while avoiding a rapid decrease that could lead to cerebral edema. Insulin infusions allow for precise control of the rate and can be adjusted as needed based on the patient’s response.

Choice B rationale:

Giving a long-acting insulin dose is not typically done during the acute treatment of DKA. The patient has already taken a dose of insulin glargine at home. Additional doses of long-acting insulin could potentially lead to hypoglycemia.

Choice C rationale:

Providing an oral medication that enhances insulin production would not be beneficial in this case. The patient has type 1 diabetes, which means her body does not produce insulin. Therefore, medications that stimulate insulin production would not be effective.

Choice D rationale:

Changing the intravenous fluid to 5% dextrose and 0.45% sodium chloride with 20 mEq potassium can help prevent hypoglycemia and hypokalemia, which are potential complications of DKA treatment. As blood glucose levels decrease with treatment, dextrose can help maintain appropriate glucose levels. Potassium is often depleted in DKA and needs to be replaced.

Choice E rationale:

Having the client drink as much as they can tolerate would not be appropriate at this time. The patient is currently experiencing nausea and vomiting, which could be exacerbated by oral fluid intake. Additionally, she is NPO (nothing by mouth), likely due to her unstable condition.

Choice F rationale:

Giving 1 L of 0.9% sodium chloride IV can help correct dehydration, which is common in DKA due to excessive urination caused by high blood glucose levels.

Choice G rationale:

Promoting removal of electrolytes with a diuretic would not be beneficial in this case. The patient is likely already dehydrated and may have electrolyte imbalances due to DKA. Using a diuretic could exacerbate these issues.

Choice H rationale:

Giving a multivitamin is not typically part of the acute treatment for DKA. While overall nutritional status is important in managing diabetes, it would not address the immediate concerns of hyperglycemia and acidosis in DKA.

Choice I rationale:

Replacing potassium as needed is crucial in the treatment of DKA. Potassium levels can drop rapidly during treatment as insulin allows potassium to move back into cells. Low potassium (hypokalemia) can cause dangerous heart rhythms and muscle weakness.

Choice A rationale:

Stopping the heparin infusion immediately is essential when the client's aPTT is significantly elevated (in this case, 120 seconds). A prolonged aPTT indicates a higher risk of bleeding, and discontinuing the heparin infusion is a crucial step in preventing further bleeding.

Choice B rationale:

Administering protamine sulfate is necessary when a client on heparin therapy experiences excessive bleeding or if the aPTT is significantly elevated. Protamine sulfate acts as a heparin antagonist and can reverse the anticoagulant effects of heparin.

Choice C rationale:

Notifying the healthcare provider of the significantly prolonged aPTT is essential because it may indicate a need for adjustments in the heparin dosage or therapy. The provider can determine the appropriate course of action based on the client's clinical condition.

Choice D rationale:

Drawing a prothrombin time (PT) and international normalized ratio (INR) level is not necessary in this situation. PT and INR are more relevant parameters when assessing clients on warfarin therapy, not heparin.

Choice E rationale:

Monitoring the client for signs and symptoms of bleeding is crucial when the aPTT is prolonged, as it indicates a higher risk of bleeding. This action allows for early detection and intervention to prevent complications.