# Situation: A 76-year-old woman with type 2 diabetes mellitus is brought from home after three days of increasing drowsiness and poor oral intake during a febrile illness. She weighs 60 kg. The provider diagnoses hyperosmolar hyperglycemic state (HHS). Four hours after treatment began, the nurse evaluates her circulating volume. Her urine output target per unit protocol is at least 0.5 mL/kg/h. Which set of findings shows that her circulating volume is being restored safely?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630230  
> language: ko  
> subject: Nursing Practice V — Care of Clients with Maladaptive Patterns of Behavior; Care of Clients with Life-Threatening Conditions, Acute Multi-Organ Problems, High Acuity and Emergency Situations

## 문제

Situation: A 76-year-old woman with type 2 diabetes mellitus is brought from home after three days of increasing drowsiness and poor oral intake during a febrile illness. She weighs 60 kg. The provider diagnoses hyperosmolar hyperglycemic state (HHS).

Four hours after treatment began, the nurse evaluates her circulating volume. Her urine output target per unit protocol is at least 0.5 mL/kg/h. Which set of findings shows that her circulating volume is being restored safely?

## 보기

1. Blood pressure 108/60 mmHg, urine 20 mL/h, glucose 640 mg/dL (35.6 mmol/L), lungs clear
2. Blood pressure 88/50 mmHg, urine 90 mL/h, glucose 900 mg/dL (50.0 mmol/L), lungs clear
3. Blood pressure 122/70 mmHg, urine 50 mL/h, glucose 560 mg/dL (31.1 mmol/L), new basal crackles
4. Blood pressure 116/64 mmHg, urine 40 mL/h, glucose 610 mg/dL (33.9 mmol/L), lungs clear **✔ 정답**

**정답: 4**

## 해설

For a 60-kg client, 0.5 mL/kg/h is 30 mL/h. The set with blood pressure 116/64 mmHg shows a restored pressure, urine output above 30 mL/h, and clear lungs. A high urine output means little while glucose remains very high, because glucose in the urine causes an osmotic diuresis even when the client is still volume depleted.

## 심화 해설

Clinical context

Hyperosmolar hyperglycemic state (HHS) produces profound total-body water and electrolyte deficits because sustained hyperglycemia drives a massive osmotic diuresis. In this older adult with type 2 diabetes, three days of drowsiness and poor oral intake superimposed on a febrile illness further reduced intake while urinary losses continued. The immediate priority is not rapid correction of glucose but careful restoration of circulating volume, because hypovolemia and hyperosmolality are the main threats to cerebral and renal perfusion.

Interpreting the urine output target

The protocol target is 0.5 mL/kg/h. For a 60 kg client, the minimum acceptable urine output is 30 mL/h. This threshold is a marker of adequate renal perfusion, but it must be interpreted together with blood pressure, lung findings, and the glucose trend.

Why option 4 is the safest picture

Option 4 shows blood pressure 116/64 mmHg, urine output 40 mL/h, glucose 610 mg/dL (33.9 mmol/L), and lungs clear. The blood pressure is restored without hypertension, urine output exceeds the 30 mL/h minimum, and clear lungs indicate that fluid replacement has not tipped the client into pulmonary edema. The glucose remains elevated, which is expected at only four hours into HHS treatment; the goal at this stage is gradual reduction, not normalization.

Why high urine output alone is misleading

Glucose in the urine acts as an osmotic diuretic, so urine output can remain high even when the client is still intravascularly depleted. Option 2 demonstrates this pitfall: urine output is 90 mL/h, but blood pressure is 88/50 mmHg and glucose is 900 mg/dL (50.0 mmol/L). The low blood pressure signals ongoing hypovolemia despite brisk urine flow, because the kidneys are excreting water to clear the massive glucose load. Watch out! In hyperglycemic emergencies, urine output is not a reliable stand-alone indicator of volume status.

Why the other options fail

Option 1 has acceptable blood pressure and clear lungs, but urine output is only 20 mL/h, below the 30 mL/h target. This suggests inadequate renal perfusion or ongoing volume deficit despite a reasonable blood pressure reading.

Option 3 has good blood pressure and urine output of 50 mL/h, but new basal crackles indicate fluid is accumulating in the pulmonary interstitium and alveoli. In an older adult with possible underlying cardiac or renal vulnerability, overly rapid or excessive fluid replacement can precipitate pulmonary edema. Key point! Safe volume restoration means achieving perfusion targets without pushing the client into fluid overload.

Clinical reasoning for the licensure exam

| Finding | Option 1 | Option 2 | Option 3 | Option 4 |
| --- | --- | --- | --- | --- |
| Blood pressure | 108/60 mmHg | 88/50 mmHg | 122/70 mmHg | 116/64 mmHg |
| Urine output target 30 mL/h | 20 mL/h (below) | 90 mL/h (above) | 50 mL/h (above) | 40 mL/h (above) |
| Lung assessment | Clear | Clear | New basal crackles | Clear |
| Interpretation | Inadequate urine output | Osmotic diuresis masking hypovolemia | Fluid overload | Safe restoration |

Pathophysiology link

In HHS, the serum osmolality is markedly elevated, and the osmotic gradient pulls water from the intracellular space into the extracellular compartment. Initially this can maintain blood pressure, but as urinary glucose losses continue, total body water falls. Fluid replacement with isotonic saline restores intravascular volume and, by lowering serum osmolality gradually, reduces the osmotic drive for continued diuresis. The glucose concentration falls partly from dilution and partly from the improved renal perfusion that enhances glucose excretion once volume is restored. This is why the glucose in option 4 remains elevated at 610 mg/dL (33.9 mmol/L) yet the clinical picture is safe: the priority is perfusion, not rapid glucose correction.

Nursing priority

The nurse monitors for both under-resuscitation and over-resuscitation during HHS treatment. Under-resuscitation presents as persistent hypotension, tachycardia, poor urine output, or altered mentation. Over-resuscitation presents as crackles, dyspnea, elevated jugular venous pressure, or new oxygen desaturation. In older adults with diabetes, the margin between these two states is narrow because of reduced cardiac compliance and possible diastolic dysfunction. Frequent reassessment of vital signs, urine output, lung sounds, and neurologic status guides titration of intravenous fluids according to protocol.

## 임상 시나리오

HHS Fluid Resuscitation Safety CheckInterpreting volume status at 4 hours into treatment
For a 60 kg patient, the minimum urine output target is 30 mL/h (0.5 mL/kg/h). Safe restoration means urine output above threshold, restored blood pressure, and clear lungs.

High urine output alone is misleading in HHS because osmotic diuresis from glucosuria continues even when the patient is still volume depleted. Always pair urine output with blood pressure and lung assessment.

CautionNew crackles or dyspnea during fluid resuscitation signals pulmonary edema from overly rapid replacement. Glucose is expected to remain elevated at 4 hours; the goal is gradual reduction, not normalization.

## 핵심 개념

- **Hyperosmolar hyperglycemic state (HHS)** — A serious complication of diabetes with very high blood glucose, extreme dehydration, and hyperosmolality without significant ketosis
- **Osmotic diuresis** — Increased urine output caused by glucose in the urine pulling water with it, which can continue even when the patient is volume depleted
- **Circulating volume restoration** — The priority in HHS treatment, focusing on careful fluid replacement to improve perfusion before correcting glucose
- **Urine output target** — A marker of adequate renal perfusion, calculated as 0.5 mL/kg/h minimum in this protocol
- **Pulmonary edema** — Fluid accumulation in the lungs, a sign that fluid replacement has been too rapid or excessive

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