— 生理適應 · MEDIUM · MCQ —
一位病人因糖尿病酮酸中毒（DKA）入院。下列哪項護理行動為優先？
A client is admitted with diabetic ketoacidosis (DKA). Which nursing action is the priority?
- AObtain a complete blood count取得完整血球計數
- BInfuse 0.9% Normal Saline intravenously✓ 正解靜脈輸注 0.9% 生理食鹽水
- CAdminister subcutaneous insulin皮下注射胰島素
- DAdminister potassium chloride給予氯化鉀
— Explanation · 中文詳解 —
DKA 處置的首要步驟是補液（Fluid resuscitation）。病人因高血糖滲透性利尿導致嚴重脫水，補充生理食鹽水可稀釋血液糖分並恢復腎臟灌流。胰島素需在補液後且鉀離子確認正常後才給予，過早給胰島素會導致鉀離子迅速進入細胞引發心律不整。
The priority nursing action in diabetic ketoacidosis is immediate fluid resuscitation with 0.9% Normal Saline to restore tissue perfusion and begin lowering blood glucose levels. While insulin and potassium are essential components of treatment, they are administered only after initial fluid replacement to prevent cardiovascular collapse and ensure safe electrolyte management.
✦ 台美臨床差異
美台對 DKA 的 protocol 相似，皆強調補液為先，惟美國常有更明確的 Emergency Standing Order。