Endocrine Question #22


An older adult client with Type 2 diabetes is brought to the emergency department by his daughter. The client is found to have a blood glucose level of 623 mg/dL. The client’s daughter reports that the client recently had a gastrointestinal virus and has been confused for the last 3 hours. The diagnosis of hyperglycemic hyperosmolar syndrome (HHS) is made. What nursing intervention has the highest priority?


  1. Fluid replacement
    • Rationale:
  2. Reversal of altered mental status
    • Rationale:
  3. Insulin first then fluids
    • Rationale:
  4. Give sodium bicarbonate
    • Rationale:



The priority action is fluid replacement and correction of electrolyte imbalances. Fluid replacement is provided with Normal Saline up to 9 L in 48 hours. HHS is a life-threatening emergency in clients with diabetes and is characterized by hyperglycemia (levels may be over 600 mg/dL), hyperosmolarity, and dehydration usually without ketoacidosis. Severe dehydration occurs and may follow with neurological complications. Standard of care is to treat the underlying fluid deficit. Reversal of altered mental status cannot be singly treated; however, it may eventually return to normal following fluid homeostasis. Insulin administration prior to fluid restoration may actually increase the risk of shock. Fluid replacement may later include insulin replacement. Sodium bicarb replacement is not priority, and if not within normal ranges, may become normal following fluid replacement.

Learning Outcomes

Test Taking Tip

Video Rationale