— 生理適應 · MEDIUM · MCQ —
第一型糖尿病病患血糖值為 450 mg/dL，哪項護理措施為最高優先級？
A client with type 1 diabetes mellitus presents with a blood glucose level of 450 mg/dL. Which nursing action is the highest priority?
- APerform a physical assessment for Kussmaul respirations進行深快呼吸 (Kussmaul respirations) 的身體評估
- BCheck the client's urine for ketones檢查個案尿液中的酮體
- CInitiate an intravenous infusion of 0.9% normal saline✓ 正解開始輸注0.9%生理食鹽水
- DAdminister subcutaneous regular insulin給予皮下注射常規胰島素
— Explanation · 中文詳解 —
第一型糖尿病病患出現極高血糖（450 mg/dL），常伴隨糖尿病酮酸中毒（DKA）或高滲透壓高血糖狀態（HHS）。首要優先級是「循環穩定」，因為高血糖導致滲透性利尿，造成嚴重脫水與電解質流失。補充等張溶液（0.9% Normal saline）可擴張血容量，改善腎灌流以利葡萄糖排出，並為後續胰島素治療奠定基礎。
The highest priority is initiating an intravenous infusion of 0.9% normal saline to address severe dehydration caused by osmotic diuresis from hyperglycemia. Restoring intravascular volume improves tissue perfusion and renal function, which is essential before administering insulin to safely lower blood glucose levels.