# The 74-year-old client with type 2 diabetes and stage 3 chronic kidney disease (baseline creatinine 1.4 mg/dL) has had fever and poor oral intake for 3 days and is now drowsy and disoriented. The client follows simple commands and moves all extremities equally with no facial droop. Mucous membranes are dry. Blood pressure is 92/54 mm Hg, heart rate 112/min, temperature 37.8°C (100.0°F), and SpO2 97% on room air. Laboratory results: glucose 824 mg/dL, effective serum osmolality 326 mOsm/kg, pH 7.36, bicarbonate 20 mEq/L, serum beta-hydroxybutyrate 1.2 mmol/L, potassium 3.4 mmol/L, and creatinine 2.3 mg/dL. The prescriber has written orders for isotonic crystalloid, IV potassium replacement, and an insulin infusion. 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.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=617379&lang=en  
> language: en  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PPT

## Question

The 74-year-old client with type 2 diabetes and stage 3 chronic kidney disease (baseline creatinine 1.4 mg/dL) has had fever and poor oral intake for 3 days and is now drowsy and disoriented. The client follows simple commands and moves all extremities equally with no facial droop. Mucous membranes are dry. Blood pressure is 92/54 mm Hg, heart rate 112/min, temperature 37.8°C (100.0°F), and SpO2 97% on room air. Laboratory results: glucose 824 mg/dL, effective serum osmolality 326 mOsm/kg, pH 7.36, bicarbonate 20 mEq/L, serum beta-hydroxybutyrate 1.2 mmol/L, potassium 3.4 mmol/L, and creatinine 2.3 mg/dL. The prescriber has written orders for isotonic crystalloid, IV potassium replacement, and an insulin infusion. 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.

Condition

Select 1
Hyperglycemic hyperosmolar state
Diabetic ketoacidosis
Combined DKA and hyperosmolar state
Acute ischemic stroke

Actions to take

Select 2
Infuse 0.45% sodium chloride as a rapid bolus
Administer the prescribed IV sodium bicarbonate
Infuse the prescribed isotonic crystalloid
Restrict fluids because of kidney disease
Give the prescribed IV potassium replacement

Parameters to monitor

Select 2
Serum potassium
Anion gap
Serum beta-hydroxybutyrate level
Effective serum osmolality
NIH Stroke Scale score

## Explanation

Glucose above 600 mg/dL, effective osmolality above 300 mOsm/kg, pH 7.36, and only mildly raised ketones indicate HHS rather than DKA. Isotonic crystalloid treats the severe volume deficit and prerenal kidney injury, and IV potassium corrects a level of 3.4 mmol/L that treatment will push lower. Serum potassium and effective osmolality are trended to keep potassium in range and to lower osmolality gradually.

## In-depth explanation

Quick answer
Hyperglycemic hyperosmolar state. Actions: infuse the prescribed isotonic crystalloid; give the prescribed IV potassium replacement. Monitor: serum potassium, and effective serum osmolality.

Why this is correct
The 2024 hyperglycemic crises consensus defines HHS by marked hyperglycemia and effective osmolality above 300 mOsm/kg without significant ketoacidosis. The client is profoundly volume depleted and hypotensive, so isotonic fluid restores circulation and kidney perfusion and lowers glucose by itself. Potassium is already low at 3.4 mmol/L and falls further as glucose is lowered, so it is replaced and rechecked. Osmolality is lowered gradually to prevent cerebral edema.

Easy analogy or mental picture
HHS is a raisin that has lost its water: soak it slowly in balanced fluid and keep the minerals (potassium) topped up while it plumps back.

Memory hook
HHS: isotonic in, potassium up, osmolality down slowly.

NCLEX decision rule
In a hyperglycemic crisis with hypotension, treat the volume deficit with isotonic fluid, correct a low potassium, and lower osmolality gradually.

Why the other choices are wrong
DKA is ruled out by pH 7.36, bicarbonate 20 mEq/L, and beta-hydroxybutyrate 1.2 mmol/L; a mixed state would need both HHS and significant ketoacidosis. Anion gap and ketone trends therefore track the wrong process. Stroke is tempting in a drowsy older client, but the neurologic exam is nonfocal and hyperosmolality explains the drowsiness, so the NIH Stroke Scale is not the progress measure. Hypotonic 0.45% saline given rapidly is not the fluid for hypotension with a severe volume deficit and can drop osmolality too fast. Bicarbonate is not indicated at this pH. Restricting fluids for CKD is tempting, but the kidney injury is prerenal from dehydration and needs fluid.

References
1Hyperglycemic Crises in Adults With Diabetes: A Consensus Report (Diabetes Care, 2024)Diagnostic criteria for HHS and guidance on isotonic fluid, potassium replacement, and gradual osmolality correction.

## Clinical scenario

Case update
An older client with type 2 diabetes and CKD has glucose 824 mg/dL, effective osmolality 326 mOsm/kg, pH 7.36, low ketones, potassium 3.4 mmol/L, hypotension, and acute kidney injury.

## Key concepts

- **Effective serum osmolality** — 2 x sodium + glucose/18; a value above 300 mOsm/kg supports HHS.
- **Hyperglycemic hyperosmolar state** — A hyperglycemic crisis with severe dehydration and hyperosmolality but little or no ketoacidosis.
- **Insulin-driven potassium shift** — Insulin moves potassium into cells and can cause severe hypokalemia if started while potassium is low.

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