— 生理適應 · HARD · SATA —
一名第一型糖尿病病人血糖 450 mg/dL，尿液出現酮體，且呈現庫斯莫爾呼吸。護理師應採取哪些措施？（選所有適合的）
A client with type 1 diabetes mellitus presents with a blood glucose of 450 mg/dL, ketones in urine, and Kussmaul respirations. What nursing actions are appropriate? (Select all that apply.)
- AAdminister regular insulin via IV bolus and infusion✓ 正解經靜脈推注及輸注速效胰島素
- BInitiate isotonic saline fluid replacement✓ 正解開始等滲鹽水補充液體
- CMonitor serum potassium levels closely✓ 正解密切監測血清鉀濃度
- DEncourage oral intake of carbohydrate-rich fluids鼓勵口服攝取富含碳水化合物的液體
- EAssess neurological status every hour✓ 正解每小時評估神經狀態
— Explanation · 中文詳解 —
病人呈現 DKA（糖尿病酮酸中毒），應立即給予靜脈輸液（生理食鹽水）擴充容積，並以靜脈輸注胰島素降低血糖。治療過程中鉀離子會隨胰島素進入細胞而下降，必須嚴密監控血鉀。庫斯莫爾呼吸為補償性代謝性酸中毒，病人意識狀態需密切評估。
The priority interventions for diabetic ketoacidosis include initiating isotonic saline fluid replacement to restore volume and administering intravenous insulin to halt ketone production. Close monitoring of serum potassium is essential because insulin therapy drives potassium into cells, risking hypokalemia, while hourly neurological assessments help detect cerebral edema.
✦ 台美臨床差異
美台皆將 DKA 列為危急值處理，但美國醫學中心多設有 DKA protocol，台灣則視各院臨床路徑而定。