COMPREHENSIVE PROFESSIONAL NURSING
EXAMINATION
Advanced Clinical Management of Pediatric & Adolescent Diabetic
Ketoacidosis (DKA)
200 Rigorous Clinical Questions with Detailed Rationales
Question 1: A nurse is caring for an adolescent who has type 1 diabetes
mellitus and is admitted to the emergency department with diabetic
ketoacidosis (DKA). Which of the following intravenous (IV) fluids
should the nurse anticipate administering initially?
A. 0.45% Sodium Chloride (Half-Normal Saline)
B. 0.9% Sodium Chloride (Normal Saline)
C. 5% Dextrose in 0.9% Sodium Chloride
D. Lactated Ringer's Solution with 5% Dextrose
Correct Answer: B
Rationale: Initial fluid resuscitation for pediatric and adolescent DKA
focuses on expanding intravascular volume and restoring tissue
perfusion. Isotonic 0.9% Sodium Chloride is the initial fluid of choice
administered at 10 to 20 mL/kg over the first 1 to 2 hours. Hypotonic
fluids (such as 0.45% NaCl) are introduced later once intravascular
volume is stabilized and serum sodium levels are evaluated, to prevent
too rapid a decline in serum osmolality which risks cerebral edema.
,Question 2: Following initial fluid resuscitation with 0.9% Sodium
Chloride in an adolescent with DKA, the client's blood pressure
stabilizes and serum sodium is calculated as normal to high. Which IV
fluid formulation should the nurse anticipate transitioning to next?
A. 0.9% Sodium Chloride at a rapid bolus rate
B. 0.45% Sodium Chloride with or without potassium chloride
C. 5% Dextrose in Water (D5W) without electrolytes
D. Plain Sterile Water for injection IV
Correct Answer: B
Rationale: After initial volume expansion with 0.9% NaCl,
replacement fluids are typically changed to 0.45% Sodium Chloride
infused at a rate calculated to replace remaining deficit and
maintenance needs evenly over 24 to 48 hours. Potassium chloride is
added once urine output is established.
Question 3: An adolescent with DKA has a blood glucose level of 420
mg/dL upon admission. When should the nurse anticipate adding 5%
dextrose to the IV fluid regimen?
A. Immediately upon initiation of insulin infusion
B. When blood glucose levels decrease to less than 250 mg/dL
C. Only when the patient reports symptoms of hypoglycemia
D. When blood glucose reaches exactly zero
Correct Answer: B
Rationale: Dextrose (typically 5%) is added to IV replacement fluids
(e.g., D5 0.45% NaCl) when blood glucose reaches 250 to 300 mg/dL.
This prevents rapid hypoglycemia and cerebral edema caused by too-
rapid serum osmolality reduction while allowing continued insulin
, administration necessary to clear ketoacids.
Question 4: Which of the following assessments is the highest priority
for the nurse monitoring an adolescent receiving IV fluid resuscitation
and insulin therapy for DKA?
A. Daily morning weight measurement
B. Neurological status and mental acuity assessments every 1 hour
C. Dietary caloric intake tracking every shift
D. Bowel sound auscultation every 4 hours
Correct Answer: B
Rationale: Neurological monitoring (checking for headache, lethargy,
confusion, bradycardia, or altered level of consciousness) is
paramount due to the risk of cerebral edema—a life-threatening
complication in pediatric and adolescent DKA treatment. Frequent
neurological checks (every 1 hour) allow for early detection and rapid
intervention.
, Question 5: An adolescent with DKA is admitted with a serum
potassium level of 3.2 mEq/L. The healthcare provider's prescription
includes regular insulin infusion and IV fluids. What is the nurse's most
appropriate initial action regarding the insulin infusion?
A. Initiate the regular insulin infusion immediately as prescribed.
B. Hold the insulin infusion and ensure potassium replacement is
initiated first until potassium is > 3.3 mEq/L.
C. Administer a double dose of insulin to counteract hypokalemia.
D. Switch insulin to subcutaneous route immediately.
Correct Answer: B
Rationale: Insulin drives potassium into cells, which further lowers
serum potassium levels. If serum potassium is below 3.3 mEq/L,
insulin must be withheld until potassium is corrected to above 3.3
mEq/L to prevent fatal cardiac dysrhythmias or arrest.
Question 6: Which clinical manifestation is a classic hallmark finding in
an adolescent presenting with diabetic ketoacidosis?
A. Kussmaul respirations with a fruity breath odor
B. Bradycardia and hypertension
C. Hypothermia and moist, diaphoretic skin
D. Perorbital edema and polycythemia
Correct Answer: A
Rationale: Kussmaul respirations (deep, rapid breathing) represent
the respiratory system's compensatory mechanism for metabolic
acidosis (blowing off carbon dioxide). Acetone breath gives off a
characteristic fruity or sweet odor. Dehydration causes dry mucous
membranes and tachycardia, not bradycardia or moist skin.
EXAMINATION
Advanced Clinical Management of Pediatric & Adolescent Diabetic
Ketoacidosis (DKA)
200 Rigorous Clinical Questions with Detailed Rationales
Question 1: A nurse is caring for an adolescent who has type 1 diabetes
mellitus and is admitted to the emergency department with diabetic
ketoacidosis (DKA). Which of the following intravenous (IV) fluids
should the nurse anticipate administering initially?
A. 0.45% Sodium Chloride (Half-Normal Saline)
B. 0.9% Sodium Chloride (Normal Saline)
C. 5% Dextrose in 0.9% Sodium Chloride
D. Lactated Ringer's Solution with 5% Dextrose
Correct Answer: B
Rationale: Initial fluid resuscitation for pediatric and adolescent DKA
focuses on expanding intravascular volume and restoring tissue
perfusion. Isotonic 0.9% Sodium Chloride is the initial fluid of choice
administered at 10 to 20 mL/kg over the first 1 to 2 hours. Hypotonic
fluids (such as 0.45% NaCl) are introduced later once intravascular
volume is stabilized and serum sodium levels are evaluated, to prevent
too rapid a decline in serum osmolality which risks cerebral edema.
,Question 2: Following initial fluid resuscitation with 0.9% Sodium
Chloride in an adolescent with DKA, the client's blood pressure
stabilizes and serum sodium is calculated as normal to high. Which IV
fluid formulation should the nurse anticipate transitioning to next?
A. 0.9% Sodium Chloride at a rapid bolus rate
B. 0.45% Sodium Chloride with or without potassium chloride
C. 5% Dextrose in Water (D5W) without electrolytes
D. Plain Sterile Water for injection IV
Correct Answer: B
Rationale: After initial volume expansion with 0.9% NaCl,
replacement fluids are typically changed to 0.45% Sodium Chloride
infused at a rate calculated to replace remaining deficit and
maintenance needs evenly over 24 to 48 hours. Potassium chloride is
added once urine output is established.
Question 3: An adolescent with DKA has a blood glucose level of 420
mg/dL upon admission. When should the nurse anticipate adding 5%
dextrose to the IV fluid regimen?
A. Immediately upon initiation of insulin infusion
B. When blood glucose levels decrease to less than 250 mg/dL
C. Only when the patient reports symptoms of hypoglycemia
D. When blood glucose reaches exactly zero
Correct Answer: B
Rationale: Dextrose (typically 5%) is added to IV replacement fluids
(e.g., D5 0.45% NaCl) when blood glucose reaches 250 to 300 mg/dL.
This prevents rapid hypoglycemia and cerebral edema caused by too-
rapid serum osmolality reduction while allowing continued insulin
, administration necessary to clear ketoacids.
Question 4: Which of the following assessments is the highest priority
for the nurse monitoring an adolescent receiving IV fluid resuscitation
and insulin therapy for DKA?
A. Daily morning weight measurement
B. Neurological status and mental acuity assessments every 1 hour
C. Dietary caloric intake tracking every shift
D. Bowel sound auscultation every 4 hours
Correct Answer: B
Rationale: Neurological monitoring (checking for headache, lethargy,
confusion, bradycardia, or altered level of consciousness) is
paramount due to the risk of cerebral edema—a life-threatening
complication in pediatric and adolescent DKA treatment. Frequent
neurological checks (every 1 hour) allow for early detection and rapid
intervention.
, Question 5: An adolescent with DKA is admitted with a serum
potassium level of 3.2 mEq/L. The healthcare provider's prescription
includes regular insulin infusion and IV fluids. What is the nurse's most
appropriate initial action regarding the insulin infusion?
A. Initiate the regular insulin infusion immediately as prescribed.
B. Hold the insulin infusion and ensure potassium replacement is
initiated first until potassium is > 3.3 mEq/L.
C. Administer a double dose of insulin to counteract hypokalemia.
D. Switch insulin to subcutaneous route immediately.
Correct Answer: B
Rationale: Insulin drives potassium into cells, which further lowers
serum potassium levels. If serum potassium is below 3.3 mEq/L,
insulin must be withheld until potassium is corrected to above 3.3
mEq/L to prevent fatal cardiac dysrhythmias or arrest.
Question 6: Which clinical manifestation is a classic hallmark finding in
an adolescent presenting with diabetic ketoacidosis?
A. Kussmaul respirations with a fruity breath odor
B. Bradycardia and hypertension
C. Hypothermia and moist, diaphoretic skin
D. Perorbital edema and polycythemia
Correct Answer: A
Rationale: Kussmaul respirations (deep, rapid breathing) represent
the respiratory system's compensatory mechanism for metabolic
acidosis (blowing off carbon dioxide). Acetone breath gives off a
characteristic fruity or sweet odor. Dehydration causes dry mucous
membranes and tachycardia, not bradycardia or moist skin.
