Clinical context: An adult with type 2 diabetes takes empagliflozin. During 2 days of fever and minimal oral intake from a urinary infection (temperature 38.7°C [101.7°F], dysuria, pyuria), the client developed repeated vomiting and deep, rapid respirations. Mucous membranes are dry and the abdomen is soft without guarding. No recent alcohol intake is reported. Results: glucose 184 mg/dL, venous pH 7.24, bicarbonate 12 mEq/L, beta-hydroxybutyrate 5.2 mmol/L, lactate 1.4 mmol/L, creatinine 0.9 mg/dL, and last A1C 7.2%. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Quick answer
Euglycemic diabetic ketoacidosis. Hold empagliflozin and notify the provider; start isotonic IV fluid and the IV insulin infusion. Monitor serum beta-hydroxybutyrate and the anion gap.

Why this is correct
SGLT2 inhibitors lower glucose by spilling it into the urine, so ketoacidosis can develop while glucose stays under 250 mg/dL, especially during infection, vomiting, and poor intake. A pH of 7.24, bicarbonate of 12 mEq/L, and beta-hydroxybutyrate of 5.2 mmol/L meet DKA criteria. Isotonic fluid corrects the volume loss from vomiting and glucosuria, and insulin is still required to stop ketogenesis; glucose is checked frequently so the infusion can continue safely while ketones clear.

Easy analogy or mental picture
The empagliflozin keeps draining sugar out of the tank, so the fuel gauge (glucose) reads almost normal while the engine is burning the wrong fuel (ketones). Look at the exhaust, not the gauge.

Memory hook
"SGLT2 + sick + acidotic = check ketones, not glucose." Insulin runs until the ketones clear.

NCLEX decision rule
When a client on an SGLT2 inhibitor is ill with vomiting or tachypnea, a normal-looking glucose does not exclude DKA; treat and trend by ketones and acid-base values.

Why the other choices are wrong
Starvation ketosis follows poor intake too, but it rarely drops bicarbonate below 18 mEq/L, so oral carbohydrate with a delayed recheck under-treats this acidosis. Alcoholic ketoacidosis needs recent heavy drinking, which is absent, so thiamine and alcohol levels do not address this problem. Lactic acidosis from sepsis is ruled out by a lactate of 1.4 mmol/L, so lactate does not track progress. Bicarbonate is not indicated at a pH of 7.24, and osmolality monitors HHS, which requires marked hyperglycemia.