# A 74-year-old client with type 2 diabetes and stage 3 chronic kidney disease has HHS with BP 92/54 mm Hg, glucose 824 mg/dL, effective osmolality 326 mOsm/kg, potassium 3.4 mmol/L, drowsiness, and acute kidney injury. Place the treatment actions in the safest sequence. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=522070&lang=en > language: en > subject: Adverse Effects/Contraindications/Interactions > category: PPT ## Question A 74-year-old client with type 2 diabetes and stage 3 chronic kidney disease has HHS with BP 92/54 mm Hg, glucose 824 mg/dL, effective osmolality 326 mOsm/kg, potassium 3.4 mmol/L, drowsiness, and acute kidney injury. Place the treatment actions in the safest sequence. Begin cautious isotonic crystalloid and obtain time-stamped glucose, electrolytes, creatinine, and osmolality. Replace potassium and continue cardiac monitoring because potassium is 3.4 mmol/L. Transition to subcutaneous therapy only after resolution criteria and an overlap plan are met. Start the authorized short-acting insulin infusion after potassium exceeds 3.5 mmol/L and the initial fluid response is assessed. Add dextrose and adjust insulin when glucose approaches the protocol threshold while osmolality continues to normalize. ## Explanation The sequence restores perfusion, corrects potassium below 3.5 mmol/L before insulin, begins insulin safely, adds dextrose while hyperosmolality continues to resolve, and transitions only after HHS resolution criteria and insulin overlap are met. ## In-depth explanation Quick answer Sequence cautious fluid, potassium, insulin, dextrose adjustment, then transition. Why this is correct Fluids address hypovolemia first. Because potassium is 3.4 mmol/L, replacement and monitoring precede insulin. Dextrose is added as glucose falls so insulin can continue while osmolality and cognition recover; transition follows resolution and overlap planning. Easy analogy or mental picture Treat HHS like restoring a concentrated circulation system: refill carefully, protect potassium, then lower glucose and osmolality at a controlled rate. Memory hook Fluid, potassium, insulin, dextrose, transition. NCLEX decision rule Use the client's current potassium and perfusion to order the first steps, then require objective HHS resolution before transition. Why the other choices are wrong Starting insulin before potassium correction risks arrhythmia, and stopping treatment when glucose alone improves can leave hyperosmolality unresolved.References 12024 Consensus Report: Hyperglycemic Crises in Adults With DiabetesHHS diagnosis, cautious fluids, potassium and insulin safety, controlled osmolality correction, and resolution criteria ## Clinical scenario Safe HHS treatment sequence Order the actions by immediate physiologic priority and use glucose, osmolality, urine output, cognition, and insulin overlap to judge transition readiness. ## Related questions - [A client is admitted to the emergency department after ingesting an unknown amount of acet…](https://mymerci.kr/pages/nclex_q.php?qn_id=362720&lang=en) - [A client with chronic heart failure is prescribed metoprolol 25 mg orally twice daily. Bef…](https://mymerci.kr/pages/nclex_q.php?qn_id=362756&lang=en) - [A 28-year-old client with type 1 diabetes receives regular insulin 6 units and NPH insulin…](https://mymerci.kr/pages/nclex_q.php?qn_id=362792&lang=en) - [A client receives IV vancomycin 1 g every 12 hours for MRSA bacteremia. Before the next do…](https://mymerci.kr/pages/nclex_q.php?qn_id=362833&lang=en) - [A client with bipolar disorder has been taking lithium carbonate 600 mg orally three times…](https://mymerci.kr/pages/nclex_q.php?qn_id=362894&lang=en) - [A nurse is monitoring a client receiving a continuous IV heparin infusion for pulmonary em…](https://mymerci.kr/pages/nclex_q.php?qn_id=363988&lang=en) - [A nurse is preparing to initiate a weight-based continuous IV unfractionated heparin infus…](https://mymerci.kr/pages/nclex_q.php?qn_id=364107&lang=en) - [A nurse is providing discharge teaching to a 65-year-old client newly prescribed warfarin …](https://mymerci.kr/pages/nclex_q.php?qn_id=364872&lang=en) ## Read in another language - [en](https://mymerci.kr/pages/nclex_q.php?qn_id=522070&lang=en) - [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=522070&lang=ko) - [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=522070&lang=ja) - [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=522070&lang=zh-tw) - [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=522070&lang=vi) --- More free questions: [NCLEX-RN Practice](https://mymerci.kr/pages/nclex_bank.php?lang=en) _For study reference only. Always follow current clinical guidelines and your institution’s protocols._