— 生理適應 · MEDIUM · MCQ —
一位第一型糖尿病病人入院，血糖值 450 mg/dL 且呼氣有爛蘋果味。護理師應採取之首要措施為何？
A client with type 1 diabetes mellitus presents with a blood glucose level of 450 mg/dL and a fruity odor to the breath. Which intervention is the nurse's priority?
- APerform a capillary blood glucose test進行指尖血糖測試
- BAdminister subcutaneous NPH insulin施打皮下NPH胰島素
- CInitiate intravenous fluids with 0.9% normal saline✓ 正解開始輸注0.9%生理食鹽水
- DProvide 8 ounces of orange juice提供8盎司柳橙汁
— Explanation · 中文詳解 —
此病人出現酮酸中毒（DKA）徵兆。處理 DKA 首要工作是擴張血管容積，以改善灌流及降低血糖。需使用生理食鹽水進行靜脈輸液，隨後給予靜脈輸注規律胰島素。NPH 不適用於急症；果汁會導致血糖惡化；檢查血糖已做過。
This patient is showing signs of diabetic ketoacidosis (DKA). The first priority in managing DKA is to expand intravascular volume to improve perfusion and lower blood glucose; intravenous normal saline is used, followed by a continuous IV infusion of regular insulin. NPH insulin is not appropriate for emergencies; juice would worsen hyperglycemia; and the blood glucose check has already been done.
✦ 台美臨床差異
美國護理師常依據 DKA protocol 自行掛點滴，台灣臨床則需取得醫師醫囑後才執行靜脈輸液。