# A 73-year-old client with type 2 diabetes is admitted from a long-term care facility after 4 days of poor intake and increasing drowsiness. Laboratory results: glucose 920 mg/dL, sodium 136 mEq/L, potassium 4.1 mEq/L, chloride 102 mEq/L, bicarbonate 19 mEq/L, BUN 52 mg/dL, creatinine 2.0 mg/dL, arterial pH 7.33, serum beta-hydroxybutyrate 1.4 mmol/L, urine ketones small. Which interpretations of these results are accurate? Select all that apply.

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> subject: Laboratory Values  
> category: ROR

## Question

A 73-year-old client with type 2 diabetes is admitted from a long-term care facility after 4 days of poor intake and increasing drowsiness. Laboratory results: glucose 920 mg/dL, sodium 136 mEq/L, potassium 4.1 mEq/L, chloride 102 mEq/L, bicarbonate 19 mEq/L, BUN 52 mg/dL, creatinine 2.0 mg/dL, arterial pH 7.33, serum beta-hydroxybutyrate 1.4 mmol/L, urine ketones small. Which interpretations of these results are accurate? Select all that apply.

1The first liter of fluid should be 0.45% sodium chloride given the osmolality.
2The corrected sodium is elevated, reflecting a large free-water deficit.
3The anion gap of 15 mEq/L shows that ketoacidosis is the primary disorder.
4The effective serum osmolality exceeds the threshold used to define HHS.
5Insulin infusion should begin before fluid replacement to lower glucose fast.
6Small urine ketones with this beta-hydroxybutyrate level fit HHS.
7The BUN-to-creatinine ratio suggests prerenal azotemia from volume loss.
8Potassium of 4.1 mEq/L means no replacement is needed once insulin starts.

## Explanation

Effective osmolality is 2(136) + 920/18, about 323 mOsm/kg, and pH 7.33 with beta-hydroxybutyrate 1.4 mmol/L means HHS with only mild ketosis, not DKA. Corrected sodium is about 149 mEq/L or higher, so the free-water deficit is large, and a BUN-to-creatinine ratio of 26 indicates prerenal azotemia. The first fluid is still 0.9% saline, fluids start before insulin, and potassium of 4.1 mEq/L requires replacement once insulin starts.

## In-depth explanation

Quick answer
Options 6, 4, 2, and 7 are accurate interpretations.

Why this is correct
Effective osmolality = 2 x sodium + glucose/18 = 272 + 51, about 323 mOsm/kg, well above HHS thresholds. Beta-hydroxybutyrate 1.4 mmol/L is below the ketoacidosis range (3.0 mmol/L or higher), and pH 7.33 with bicarbonate 19 mEq/L is not acidemic, so small urine ketones from 4 days of starvation fit HHS. Corrected sodium adds at least 1.6 mEq/L per 100 mg/dL glucose above 100: 136 + 13 = about 149 mEq/L, revealing hypernatremic dehydration hidden by the glucose. BUN 52 / creatinine 2.0 = 26, a prerenal pattern from volume depletion.

Easy analogy or mental picture
Glucose in the blood acts like a sponge pulling water out of cells into the vessels; it dilutes the sodium you measure, so you must mentally squeeze the sponge back out to see the true sodium.

Memory hook
HHS = sugar sky-high, sodium secretly high, acid barely there. Fluids first, 0.9% first, potassium before it falls.

NCLEX decision rule
When hyperglycemic crisis findings overlap, decide by the numbers that define each disorder (osmolality, ketone level, pH, bicarbonate), not by whether any ketones or any anion gap are present.

Why the other choices are wrong
Anion gap as proof of DKA (option 3): tempting because DKA is a gap acidosis, but a gap of 15 mEq/L with pH 7.33 and low beta-hydroxybutyrate is explained by mild starvation ketosis and renal hypoperfusion. 0.45% saline first (option 1): tempting because the client is hyperosmolar, but initial resuscitation uses 0.9% saline; hypotonic fluid is considered later based on corrected sodium. Insulin before fluids (option 5): tempting because glucose is extreme, but in HHS fluid alone lowers glucose substantially, and early insulin can drop osmolality and circulating volume too quickly. No potassium needed (option 8): tempting because 4.1 mEq/L is normal, but insulin shifts potassium into cells, so replacement is given when potassium is below about 5.0 mEq/L and urine output is adequate.

References
1Hyperosmolar Hyperglycemic Syndrome (StatPearls)Diagnostic features of HHS, mild ketosis, fluid-first management with isotonic saline
2ADA Standards of Care in Diabetes-2025Hyperglycemic crisis criteria and potassium replacement during insulin therapy

## Clinical scenario

Scenario
An older adult with type 2 diabetes presents with drowsiness, extreme hyperglycemia, mild ketosis, and near-normal pH after several days of poor intake.

## Key concepts

- **Effective serum osmolality** — Calculated as 2 x sodium + glucose/18; it reflects the tonicity that pulls water from cells and excludes urea.
- **Corrected sodium** — Measured sodium adjusted upward for hyperglycemia to estimate the sodium level once glucose is lowered.
- **Prerenal azotemia** — Rise in BUN and creatinine from reduced kidney perfusion, typically with a BUN-to-creatinine ratio above 20.

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