一位第一型糖尿病患血糖 350 mg/dL 且呼吸有水果味。下列何項評估為優先？
A nurse is caring for a client with type 1 diabetes who presents with a blood glucose of 350 mg/dL and fruity breath odor. Which assessment is the priority?
- AAssess skin turgor評估皮膚彈性
- BAuscultate lung sounds聽診肺部聲音
- CEvaluate arterial blood gases✓ 正解評估動脈血氣體
- DCheck for peripheral pulses檢查周邊脈搏
水果味呼吸與高血糖提示酮酸中毒（DKA）。DKA 會導致代謝性酸中毒，優先評估動脈血氣（ABG）以確認 pH 值與碳酸氫根濃度，評估嚴重程度。肺部與末梢評估雖為整體檢查一部分，但對於 DKA 的致命危機（酸中毒）判斷，ABG 具診斷性意義。
Fruity breath odor and hyperglycemia suggest diabetic ketoacidosis (DKA). DKA causes metabolic acidosis, so arterial blood gas (ABG) analysis is prioritized to confirm the pH and bicarbonate level and assess severity. Lung and peripheral assessments, although part of an overall examination, are not as diagnostically meaningful for the life-threatening complication of acidosis in DKA—the ABG provides definitive information.
美國醫護對於 DKA 的 protocol 趨向於由護理師主動執行血氣分析抽樣，台灣則多由醫師或專科護理師進行。