A nurse is reviewing guidelines to prevent diabetic ketoacidosis (DKA) during periods of illness with a client who has type 1 diabetes mellitus. Which of the following instructions should the nurse include in the teaching?

Choice A rationale Monitoring for ketones is vital during illness because physiological stress triggers the release of counter-regulatory hormones like cortisol and adrenaline. These hormones increase glucose production and promote lipolysis, leading to ketone formation. Testing urine when blood glucose exceeds 240 mg/dL allows for early detection of ketosis, which is the precursor to diabetic ketoacidosis. This proactive step helps the client seek medical intervention before life-threatening metabolic acidosis occurs during sick days. Choice B rationale During illness, the risk of dehydration is high due to fever or polyuria. However, the recommendation is to consume 120 to 180 milliliters of liquid every 30 to 60 minutes, rather than 240 to 360 milliliters every 8 hours. Frequency is key to maintaining hydration and flushing ketones from the system. Waiting 8 hours between fluid intake is insufficient to compensate for the osmotic diuresis caused by hyperglycemia, potentially exacerbating volume depletion and renal strain. Choice C rationale Blood glucose monitoring during illness should occur every 3 to 4 hours, not every 8 hours. The metabolic demands and hormonal shifts during an infection can cause rapid and unpredictable spikes in glucose levels. Frequent testing allows for timely adjustments in insulin dosing and fluid intake. An 8-hour interval is too long, as it might miss significant hyperglycemic trends that require immediate correction to prevent the progression of type 1 diabetes into a state of ketoacidosis. Choice D rationale The client should never withhold their daily dose of insulin during illness, even if they are nauseated or eating less than usual. Basal insulin requirements often increase during sickness due to the stress response and elevated levels of growth hormone and glucagon. Stopping insulin entirely will lead to a rapid rise in blood glucose and the breakdown of fats for energy, creating the very ketones that cause diabetic ketoacidosis. Dosing adjustments are made based on glucose readings.