— 生理適應 · MEDIUM · MCQ —
一名 45 歲一型糖尿病病人出現水果味口氣與深快呼吸，護理師的首要行動為何？
A 45-year-old client with Type 1 diabetes mellitus presents with fruity-smelling breath and deep, rapid respirations. Which nursing action is the priority?
- AAdminister 50% dextrose IV靜脈注射50%葡萄糖
- BCheck capillary blood glucose levels測量指尖血糖值
- CInitiate an intravenous fluid infusion of normal saline✓ 正解開始輸注正常食鹽水的靜脈輸液
- DAdminister rapid-acting insulin via subcutaneous route經皮下途徑給予速效胰島素
— Explanation · 中文詳解 —
此個案呈現糖尿病酮酸中毒（DKA）徵兆，深快呼吸為庫斯莫爾氏呼吸（Kussmaul breathing）以代償酸中毒。DKA 病人通常伴隨嚴重脫水，首要治療步驟為補充生理食鹽水以恢復循環容量與腎臟灌流，再依醫囑使用胰島素。
This client presents with signs of diabetic ketoacidosis (DKA); the deep, rapid breathing is Kussmaul respiration compensating for acidosis. Clients with DKA are usually severely dehydrated, so the first priority is to administer normal saline to restore circulating volume and renal perfusion, followed by insulin per provider order.
✦ 台美臨床差異
美國醫護對於 DKA 的初期輸液處置有明確 protocol 授權，台灣亦遵循類似準則，但在胰島素幫浦操作上更需謹慎。