一名第一型糖尿病患者血糖 350 mg/dL，呼氣有水果味，且呼吸深快。護理師最關鍵的措施為何？
A nurse is caring for a client with type 1 diabetes mellitus who presents with blood glucose of 350 mg/dL, fruity breath, and deep, rapid respirations. Which nursing action is most critical?
- APrepare for immediate hemodialysis準備立即進行血液透析
- BEncourage the client to drink orange juice鼓勵病人飲用柳橙汁
- CInitiate intravenous normal saline infusion✓ 正解開始靜脈輸注正常食鹽水
- DAdminister a rapid-acting insulin bolus subcutaneously皮下注射速效胰島素推劑量
病人的症狀（水果味呼氣、深快呼吸即庫斯毛爾氏呼吸 Kussmaul respirations）顯示已進入糖尿病酮酸中毒（DKA）。在處理 DKA 時，首要目標是補充水分以恢復細胞外液容量、糾正低血壓並改善腎臟灌流，從而幫助代謝酮體並排除多餘血糖。因此，建立靜脈通路補充等張生理食鹽水（Normal Saline, NS）是優先級最高的處置。
The client's findings (fruity breath odor and deep, rapid Kussmaul respirations) indicate diabetic ketoacidosis (DKA). The initial goal in DKA management is fluid replacement to restore extracellular volume, correct hypotension, and improve renal perfusion, which in turn helps metabolize ketones and clear excess glucose. Therefore, establishing intravenous access and infusing isotonic normal saline (NS) is the highest-priority intervention.
在美國臨床中，DKA 治療 प्रोटो콜（Protocol）通常有嚴格的補液與胰島素滴注流程，護理師需在醫師醫囑下迅速執行並監測 Anion Gap 與鉀離子變化。台灣臨床處置邏輯一致，但美國更強調單位內部的 Standardized Order Set。