# 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.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=617384&lang=en  
> language: en  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PPT

## Question

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.

Condition

Select 1
Starvation ketosis
Alcoholic ketoacidosis
Euglycemic diabetic ketoacidosis
Sepsis-related lactic acidosis

Actions to take

Select 2
Give oral carbohydrate and recheck ketones in 4 hours
Hold empagliflozin and notify the provider
Give prescribed IV sodium bicarbonate
Start isotonic IV fluid and the IV insulin infusion
Give IV thiamine before any dextrose

Parameters to monitor

Select 2
Serum lactate level
Serum beta-hydroxybutyrate
Calculated effective serum osmolality
Blood alcohol level
Serum anion gap

## Explanation

Ketonemia with a pH of 7.24 and bicarbonate of 12 mEq/L despite a glucose of 184 mg/dL in a client taking empagliflozin is euglycemic DKA. The nurse holds the SGLT2 inhibitor and starts prescribed isotonic IV fluid with an IV insulin infusion, because insulin is what stops ketone production even when glucose is near normal. Beta-hydroxybutyrate and the anion gap show whether ketoacidosis is resolving, because glucose is not a reliable marker here.

## In-depth explanation

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.

References
1DailyMed: empagliflozin prescribing information (ketoacidosis warning)SGLT2 inhibitors can cause ketoacidosis with only mildly elevated glucose; stop the drug and treat when ketoacidosis is found
2Hyperglycemic Crises in Adults With Diabetes: A Consensus Report (Diabetes Care, 2024)DKA criteria include euglycemic presentations; beta-hydroxybutyrate, pH/bicarbonate, and potassium guide fluid and insulin therapy
3Adult Diabetic Ketoacidosis (StatPearls)Isotonic fluids, IV insulin once potassium is at least 3.3 mEq/L, and serial electrolyte, ketone, and acid-base monitoring

## Clinical scenario

Case update
Ketoacidosis with glucose below 200 mg/dL in a client taking empagliflozin during a urinary infection.

## Key concepts

- **Euglycemic DKA** — Diabetic ketoacidosis with glucose below 250 mg/dL, most often linked to SGLT2 inhibitors, pregnancy, or starvation.
- **Beta-hydroxybutyrate** — The main ketone body in DKA; blood levels guide diagnosis and resolution.
- **Anion gap** — Sodium minus chloride and bicarbonate; it rises with unmeasured acids such as ketones and narrows as DKA resolves.

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