— 生理適應 · MEDIUM · MCQ —
護理師照護一位血糖值 350 mg/dL 的第一型糖尿病病人，下列何者為優先護理措施？
A nurse is caring for a client with type 1 diabetes who presents with a blood glucose level of 350 mg/dL. Which nursing intervention is the priority?
- APerform a neurological assessment進行神經學評估
- BInitiate an intravenous infusion of 0.9% normal saline✓ 正解開始輸注 0.9% 生理食鹽水
- CCheck for urinary ketones檢查尿液酮體
- DAdminister subcutaneous insulin as ordered依指示給予皮下注射胰島素
— Explanation · 中文詳解 —
第一型糖尿病病人血糖過高（350 mg/dL）時，首要考量是預防高血糖高滲透壓狀態（HHS）或糖尿病酮酸中毒（DKA）。高血糖會引發滲透性利尿，導致嚴重脫水與電解質流失。根據 ABC（Airway, Breathing, Circulation）原則，優先建立循環容積（Fluid resuscitation）是穩定病人的第一步，這能改善腎臟灌流，幫助排泄過多血糖。
In a type 1 diabetic with marked hyperglycemia (350 mg/dL), the primary concern is preventing HHS or DKA. Osmotic diuresis causes severe dehydration and electrolyte loss. Following ABC principles, fluid resuscitation with 0.9% normal saline is the first step to restore circulating volume and renal perfusion, which then enables safe insulin administration.