護理師收治一位糖尿病酮酸中毒 (DKA) 病人，評估時預期會出現哪些症狀？（選所有適合的）
A client is admitted with diabetic ketoacidosis (DKA). Which of the following findings would the nurse expect to assess? (Select all that apply.)
- ADeep, rapid respirations (Kussmaul breathing)✓ 正解深而快的呼吸（庫斯莫爾氏呼吸）
- BFruity breath odor✓ 正解呼氣帶有水果味
- CHypokalemia低血鉀
- DSerum glucose levels > 250 mg/dL✓ 正解血清葡萄糖濃度 > 250 mg/dL
- EWeight gain due to water retention因水分滯留導致體重增加
DKA 是由於胰島素缺乏導致代謝紊亂。身體為代償酸中毒會出現深快呼吸 (Kussmaul)，並透過肺部排出丙酮產生水果味氣息。高血糖 (>250) 與脫水是核心特徵。C 選項：病人在初期通常是高鉀血症（因酸中毒導致細胞內外離子交換），治療給予胰島素後鉀離子才會進入細胞導致低鉀。E 選項：DKA 常導致嚴重的滲透性利尿與脫水，表現為體重減輕而非滯留。
Clients with diabetic ketoacidosis (DKA) typically present with deep, rapid respirations (Kussmaul breathing) to compensate for metabolic acidosis and a fruity breath odor caused by acetone exhalation. Serum glucose levels are significantly elevated, usually exceeding 250 mg/dL. Although insulin therapy can lead to hypokalemia, initial serum potassium is often normal or elevated due to acidosis shifting potassium out of cells.
美國常使用標準化 DKA Protocol，護理師依據血糖值與離子數據調整輸液與給藥；台灣多由醫師個別指示調整。