— 生理適應 · EASY · MCQ —
一位第一型糖尿病病人就診時血糖為 450 mg/dL。護理師應優先採取的行動為何？
A client with type 1 diabetes mellitus presents with a blood glucose level of 450 mg/dL. Which nursing action is the priority?
- AObtain an order for intravenous normal saline✓ 正解取得靜脈注射正常食鹽水之醫囑
- BAssess for Kussmaul respirations and fruity breath odor評估庫斯莫爾氏呼吸及呼氣帶有水果味
- CAdminister subcutaneous insulin給予皮下注射胰島素
- DReview the client's dietary habits for the past 24 hours檢視病人過去24小時的飲食習慣
— Explanation · 中文詳解 —
高血糖且可能伴隨酮酸中毒，首要任務是恢復循環容量。高血糖導致滲透性利尿與嚴重脫水，補液是穩定病人的第一要務。A（胰島素）很重要但需在補液後進行；C（評估）雖然重要，但在發現高血糖當下，優先處置脫水更為緊急。
With hyperglycemia and possible ketoacidosis, the top priority is restoring circulating volume. Hyperglycemia causes osmotic diuresis and severe dehydration, so fluid replacement is the first essential step in stabilizing the patient. Option C (insulin) is also important but should be administered after fluid resuscitation; option B (assessment), although important, is less urgent than treating dehydration once hyperglycemia is identified.
✦ 台美臨床差異
美國護理師常依據 DKA protocol 自行啟動輸液；台灣則嚴格規定須由醫師開立靜脈輸液處方後方可執行。