護理師照護一位患有第一型糖尿病且尿液出現酮體的病人。下列哪些護理措施是適當的？（選所有適合的）
A nurse is caring for a client with type 1 diabetes mellitus who presents with ketones in the urine. Which nursing actions are appropriate? (Select all that apply.)
- AAdminister rapid-acting insulin as ordered✓ 正解依醫囑給予速效胰島素
- BEncourage fluid intake to maintain hydration✓ 正解鼓勵補充水分以維持水合狀態
- CInstruct the client to exercise vigorously to burn ketones指示病人進行劇烈運動以燃燒酮體
- DMonitor blood glucose levels frequently✓ 正解頻繁監測血糖水平
- EAssess for signs of Kussmaul respirations✓ 正解評估庫斯莫爾氏呼吸的徵象
酮尿顯示體內胰島素嚴重不足，脂肪代謝產生酮體導致酸中毒。處置重點為補充胰島素降糖與代謝酮體、補充水分避免脫水、監控血糖以防低血糖反應，並觀察代謝性酸中毒的表徵（如代償性深快呼吸）。運動會加速脂肪分解導致酮體增加，故應避免。
Ketonuria indicates a severe lack of insulin, with fat metabolism producing ketones that result in acidosis. Management focuses on administering insulin to lower glucose and metabolize ketones, replacing fluids to prevent dehydration, monitoring blood glucose to avoid hypoglycemia, and observing for manifestations of metabolic acidosis (such as compensatory deep, rapid breathing). Exercise accelerates lipolysis and increases ketone production and should therefore be avoided.
美台均將酮尿視為 DKA 風險指標，但美國護理師常有權限依據 sliding scale 自動調整胰島素。