一位第一型糖尿病病人因意識混亂與呼氣有水果味被送至急診，護理師應採取哪些措施？（選所有適合的）
A nurse is caring for a client with type 1 diabetes who is brought to the ED with confusion and fruity-smelling breath. Which actions should the nurse perform? (Select all that apply.)
- AInitiate continuous IV regular insulin infusion✓ 正解開始連續靜脈注射常規胰島素
- BAdminister 5% Dextrose in water (D5W) bolus immediately立即給予 5% 葡萄糖水 (D5W) 推注
- CMonitor potassium levels closely during therapy✓ 正解在治療期間密切監測鉀離子水平
- DPerform hourly urine output assessment✓ 正解進行每小時尿量評估
- EAssess neurological status every 15 to 30 minutes✓ 正解每 15 至 30 分鐘評估神經狀態
病人呈現酮酸中毒（DKA）跡象。治療重點：A（靜脈胰島素）降血糖與酮體；C（補鉀）胰島素會將鉀帶回細胞，治療期間極易發生低血鉀；D（監測尿量）評估液體置換與腎臟灌流；E（評估意識）監測腦水腫風險。B 錯誤：此時血糖過高，給予 D5W 會加重高血糖。
The client is exhibiting signs of diabetic ketoacidosis (DKA), requiring immediate treatment with continuous IV regular insulin to lower blood glucose and reverse ketosis. Potassium levels must be monitored closely because insulin drives potassium into cells, risking severe hypokalemia. Hourly urine output assessments and frequent neurological checks are also essential to evaluate fluid replacement adequacy and detect complications like cerebral edema.
美國護理師常依據 DKA 治療組合（Protocol）主動執行各項檢測；台灣通常嚴格遵照醫囑執行每項給藥與檢查。