護理師照顧一位第一型糖尿病病人，血糖為 450 mg/dL。下列哪項發現顯示病人可能正在發展為糖尿病酮酸中毒 (DKA)？
A nurse is caring for a client with type 1 diabetes who presents with a blood glucose level of 450 mg/dL. Which finding indicates the client is developing diabetic ketoacidosis (DKA)?
- AMental confusion related to hypoglycemia與低血糖相關的精神錯亂
- BDecreased serum potassium血清鉀離子降低
- CDeep, rapid respirations✓ 正解深而快的呼吸
- DElevated blood pressure血壓升高
DKA 病人因酸中毒會產生 Kussmaul 呼吸，表現為深而快的呼吸，旨在透過呼出二氧化碳以代償代謝性酸中毒。其他選項中，鉀離子通常隨酸中毒由細胞內移出至細胞外導致高血鉀，而非低血鉀；高血糖會導致脫水及低血壓；此為酮酸中毒而非低血糖。
Because of acidosis in DKA, the patient develops Kussmaul respirations, characterized by deep and rapid breathing, in order to compensate for the metabolic acidosis by exhaling carbon dioxide. Among the other options, acidosis usually causes potassium to shift from the intracellular to the extracellular space, leading to hyperkalemia rather than hypokalemia; hyperglycemia causes dehydration and hypotension; and the condition is ketoacidosis rather than hypoglycemia.
美國護理師常需參與 DKA 的胰島素 drip 滴定與電解質監測，台灣則多由醫師調整醫囑後由護理師執行。