護理師正為酮酸中毒（DKA）患者準備靜脈輸注規則胰島素，哪項護理措施是正確的？
A client is admitted with diabetic ketoacidosis (DKA). The nurse is preparing an intravenous infusion of regular insulin. Which nursing action is correct?
- AMonitor blood glucose every 6 hours每 6 小時監測血糖
- BDilute insulin in normal saline for IV infusion✓ 正解以生理食鹽水稀釋胰島素以供靜脈輸注
- CEnsure the client has potassium replacement before starting insulin確保在開始胰島素治療前補充鉀離子
- DAdminister a bolus of insulin before starting the infusion在開始輸注前給予胰島素推注劑量
治療 DKA 時，規則胰島素應以生理食鹽水稀釋進行靜脈輸注。胰島素會導致鉀離子移入細胞內，但在開始輸注前，必須先確定鉀離子濃度，若鉀離子過低則需補鉀。D 選項僅適用於特定 protocol；A 選項錯誤，DKA 病人需每小時監測血糖。
In the treatment of DKA, regular insulin should be diluted in normal saline for intravenous infusion. Insulin drives potassium into the cells; therefore, before initiating the infusion, the serum potassium level must be determined, and potassium replacement provided if the level is too low. Option D applies only to specific protocols, and Option A is incorrect because blood glucose must be monitored hourly in DKA patients.
美台 DKA protocol 在胰島素輸注稀釋濃度上大致相同，但美國常有結構化流速調整表，台灣則多由醫師個別醫囑調整。