# Situation: A 50-year-old woman with beta-thalassemia trait comes to the clinic because of fatigue and frequent urination. She has hypertension and a body mass index (BMI) of 31 kg/m². She has no signs of acute illness. She is started on metformin and empagliflozin. Three months later she calls: she has had vomiting and diarrhea since morning and cannot keep fluids down. Her glucose is 148 mg/dL (8.2 mmol/L), and she has no difficulty breathing. Which instruction should the nurse give?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630497  
> language: ko  
> subject: Nursing Practice IV — Care of Clients with Problems in Nutrition and Gastrointestinal, Metabolism and Endocrine, Perception and Coordination

## 문제

Situation: A 50-year-old woman with beta-thalassemia trait comes to the clinic because of fatigue and frequent urination. She has hypertension and a body mass index (BMI) of 31 kg/m². She has no signs of acute illness.

She is started on metformin and empagliflozin. Three months later she calls: she has had vomiting and diarrhea since morning and cannot keep fluids down. Her glucose is 148 mg/dL (8.2 mmol/L), and she has no difficulty breathing. Which instruction should the nurse give?

## 보기

1. Continue both drugs, since her glucose is in range
2. Take an extra metformin dose once she can eat again
3. Hold empagliflozin and test her ketones right away **✔ 정답**
4. Check ketones only if glucose goes above 240 mg/dL (13.3 mmol/L)

**정답: 3**

## 해설

Sodium-glucose cotransporter 2 (SGLT2) inhibitors such as empagliflozin can cause euglycemic ketoacidosis, in which ketones rise while glucose stays near normal, and vomiting with dehydration raises that risk. On sick days the drug is held as directed and ketones are checked even when glucose is normal; because she cannot keep fluids down, she also needs prompt medical review. Metformin is usually held during vomiting or dehydration as well.

## 심화 해설

Euglycemic ketoacidosis with SGLT2 inhibitors
Sodium-glucose cotransporter 2 (SGLT2) inhibitors such as empagliflozin lower glucose by making the kidneys excrete glucose in the urine. Because glucose is lost in the urine, insulin levels fall and the body shifts toward fat breakdown and ketone production. During illness with vomiting, poor intake, and dehydration, this can progress to euglycemic diabetic ketoacidosis, in which ketones and acidosis rise while glucose stays near normal or only mildly raised. A glucose of 148 mg/dL does not rule out ketoacidosis in a client taking an SGLT2 inhibitor.

The correct sick-day instruction
The nurse tells her to hold empagliflozin and to check her ketones right away, even though her glucose is in range. Because she cannot keep fluids down, she also needs prompt medical review: persistent vomiting risks dehydration, kidney injury, and ketoacidosis. Metformin is usually held during vomiting or dehydration as well, because dehydration reduces kidney clearance and raises the risk of lactic acidosis. Both drugs are restarted when she is eating and drinking normally, as directed.

| Instruction | Problem or benefit |
| --- | --- |
| Continue both drugs | Ignores ketoacidosis and dehydration risk |
| Extra metformin dose | Raises lactic acidosis risk; no effect on ketosis |
| Hold empagliflozin, test ketones now | Correct sick-day action for SGLT2 inhibitors |
| Test ketones only if glucose above 240 mg/dL | General rule; misses euglycemic ketoacidosis |

Why the 240 mg/dL rule does not apply
Many sick-day plans advise checking ketones when glucose exceeds 240 mg/dL (13.3 mmol/L). That threshold works for most clients because diabetic ketoacidosis usually comes with marked hyperglycemia. With SGLT2 inhibitors, glucose may stay low enough that the threshold is never reached, so ketones are checked during illness regardless of the glucose level. Watch out! The option with a specific number looks precise, but it applies a general rule that misses the SGLT2-specific risk.

Exam takeaway
Signs of ketoacidosis include nausea, vomiting, abdominal pain, unusual tiredness, and rapid, deep breathing; she currently has no difficulty breathing, but her vomiting alone is enough reason to check ketones and seek review. Key point! On an SGLT2 inhibitor, illness with vomiting or dehydration means: hold the drug, check ketones even with normal glucose, and seek prompt medical review.

## 임상 시나리오

SGLT2 Inhibitor Sick-Day RulesEuglycemic ketoacidosis risk
Empagliflozin can cause euglycemic ketoacidosis: ketones rise while glucose stays near normal. Vomiting and dehydration increase the risk.

During illness, hold the SGLT2 inhibitor as directed and check ketones even when glucose is normal, such as her 148 mg/dL.

Metformin is usually held during vomiting or dehydration. A client who cannot keep fluids down needs prompt medical review.

CautionWaiting for glucose to exceed 240 mg/dL before testing ketones can miss ketoacidosis in clients on SGLT2 inhibitors.

## 핵심 개념

- **SGLT2 inhibitor** — A drug such as empagliflozin that lowers glucose by increasing urinary glucose excretion.
- **Euglycemic ketoacidosis** — Diabetic ketoacidosis with near-normal glucose, a known risk of SGLT2 inhibitors during illness.
- **Sick-day rules** — Instructions on adjusting diabetes drugs, monitoring, and fluids when a client is acutely ill.
- **Lactic acidosis** — A buildup of lactate in the blood, a rare but serious risk of metformin when kidney function or perfusion falls.

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