— 生理適應 · MEDIUM · MCQ —
一位第一型糖尿病病人血糖值為 450 mg/dL，且口中有水果味。護理師應優先採取的行動為何？
A client with type 1 diabetes mellitus presents with a blood glucose level of 450 mg/dL and a fruity odor to the breath. Which nursing action is the priority?
- AAdminister 0.9% normal saline IV bolus✓ 正解靜脈推注 0.9% 生理食鹽水
- BAdminister subcutaneous regular insulin皮下注射常規胰島素
- CObtain a venous blood gas取得靜脈血氣
- DCheck for urinary ketones檢查尿液酮體
— Explanation · 中文詳解 —
病人表現出高血糖（450 mg/dL）與呼氣水果味，高度懷疑為糖尿病酮酸中毒（DKA）。DKA 的首要危急生理問題是嚴重的脫水與電解質失衡。護理優先級（Priority）應遵從 ABC 原則，首先建立靜脈通道並給予生理食鹽水（Normal Saline）擴充血容量，維持組織灌流，接著才進行胰島素治療。
The client presents with hyperglycemia (450 mg/dL) and fruity breath, highly suspicious for diabetic ketoacidosis (DKA). The most urgent physiological issue in DKA is severe dehydration and electrolyte imbalance. Following ABC priorities, IV access should be established and normal saline infused first to expand volume and maintain tissue perfusion, followed by insulin therapy.