護理師照護一位第一型糖尿病病人，血糖值為 450 mg/dL。下列哪項護理措施為最高優先級？
A nurse is caring for a client with type 1 diabetes who presents with a blood glucose level of 450 mg/dL. Which nursing intervention is the highest priority?
- AObtain a urine sample for ketones取得尿液樣本進行酮體檢測
- BAdminister rapid-acting insulin per sliding scale依滑動尺度給予速效胰島素
- CAssess the client's current level of consciousness✓ 正解評估病人目前的意識水準
- DInitiate intravenous fluids as ordered依醫囑開始靜脈輸液
面對高血糖病人，護理師應遵循護理過程（Nursing Process），評估（Assessment）永遠是第一步。雖然血糖 450 mg/dL 高得驚人，可能引發糖尿病酮酸中毒（DKA）或高滲透壓高血糖狀態（HHS），但此時病人是否已出現意識障礙（Level of Consciousness, LOC）直接關係到氣道保護與生命安全。護理師必須先掌握病人的神經學基線，才能判斷需要多緊急的醫療介入。治療與檢測應在評估後緊接進行。
When facing a hyperglycemic patient, the nurse should follow the nursing process, and assessment is always the first step. Although a blood glucose of 450 mg/dL is alarmingly high and may precipitate diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS), whether the patient has any disturbance of consciousness (level of consciousness, LOC) directly affects airway protection and life safety. The nurse must first establish the patient's neurologic baseline in order to judge how urgent the required medical intervention is. Treatment and tests should follow immediately after the assessment.