一位第一型糖尿病病人血糖 450 mg/dL，出現庫氏呼吸及呼吸中有水果味。護理師應優先執行哪項措施？
A client with type 1 diabetes mellitus presents with a blood glucose level of 450 mg/dL, Kussmaul respirations, and fruity-scented breath. Which priority intervention should the nurse implement?
- AAdminister 5% Dextrose infusion給予5%葡萄糖輸注
- BObtain a clean-catch urine specimen for culture取得清潔中段尿標本進行培養
- CInitiate an intravenous infusion of 0.9% Normal Saline✓ 正解開始0.9%生理食鹽水靜脈輸注
- DAdminister a subcutaneous dose of regular insulin給予常規胰島素皮下注射劑量
此個案呈現酮酸中毒（DKA）跡象，首要目標是恢復組織灌流與補充水分。靜脈輸注生理食鹽水可擴張血管容量，降低血糖並促進腎臟代謝酮體。血糖極高時，直接補充葡萄糖會加重高滲透壓狀態；皮下胰島素吸收不穩定且效能太慢；感染篩檢雖重要但非優先級最高的復甦步驟。
This client presents with signs of diabetic ketoacidosis (DKA); the foremost goal is to restore tissue perfusion and replace fluid losses. Intravenous normal saline expands vascular volume, lowers blood glucose, and promotes renal clearance of ketone bodies. With markedly elevated glucose, giving dextrose directly would worsen the hyperosmolar state; subcutaneous insulin has unreliable absorption and an inadequate onset; infection screening is important but is not the highest-priority resuscitative step.
美台臨床對於 DKA 初期輸液給予皆依循標準化流程，台灣護理師常需更頻繁確認醫囑細節。