— 生理適應 · MEDIUM · MCQ —
一位第一型糖尿病個案因糖尿病酮酸中毒入院，下列哪項護理評估為優先？
A client with type 1 diabetes is admitted with diabetic ketoacidosis (DKA). Which nursing assessment is the priority?
- ALevel of consciousness意識程度
- BBlood glucose level血糖值
- CHydration status via skin turgor透過皮膚彈性評估水合狀態
- DSerum potassium level✓ 正解血清鉀離子濃度
— Explanation · 中文詳解 —
DKA 治療關鍵為補充胰島素及體液，但胰島素會將鉀離子快速推入細胞內，導致低血鉀引發心律不整甚至致命。因此，在開始輸注胰島素前，確認血鉀水平及確認鉀離子補充狀況是搶救生命的第一要務。意識及血糖雖重要，但心臟停跳風險更高。
The cornerstone of DKA treatment is insulin and fluid replacement, but insulin rapidly drives potassium into cells, which may cause hypokalemia, arrhythmia, and even death. Therefore, before initiating an insulin infusion, confirming the serum potassium level and that potassium replacement is in place is the top life-saving priority. Although consciousness and blood glucose are also important, the risk of cardiac arrest is greater.
✦ 台美臨床差異
台灣醫院多由醫囑監測電解質，美國護理師常依據護理常規主動進行電解質監測。