# 一位糖尿病酮酸中毒個案有黏膜乾燥、心率 122 次/分、血壓 88/54 mm Hg、血糖 560 mg/dL。護理師應首先執行哪項醫囑？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=396591&lang=zh-tw  
> language: zh-TW  
> subject: Medical Emergencies  
> category: PA

## 題目

一位糖尿病酮酸中毒個案有黏膜乾燥、心率 122 次/分、血壓 88/54 mm Hg、血糖 560 mg/dL。護理師應首先執行哪項醫囑？

## 選項

1. 給予皮下長效胰島素並讓個案出院。
2. 限制液體直到血糖低於 200 mg/dL。
3. 依醫囑開始等張靜脈輸液復甦。 **✔ 正確答案**
4. 僅在排尿停止後才給予鉀離子。

**正確答案: 3**

## 解析

DKA 通常導致嚴重脫水和低灌注，因此根據方案，等張靜脈輸液是胰島素治療前或同時進行的早期優先事項。限制液體會增加休克風險。鉀離子管理需要密切監測，而非等待無尿液排出。

## 深入解析

臨床判斷
使用個案線索、時間點、檢驗值和安全風險，選擇最符合糖尿病酮酸中毒脫水的回應。

記憶提示
將最強的線索群與最安全的護理判斷配對。

KR vs US
NCLEX 考題獎勵基於線索的優先思考，而非單獨的回憶。

## 臨床情境

臨床實務指引
對於糖尿病酮酸中毒脫水，將完整的線索模式與個案當前的穩定性、醫囑資料和預期的護理範圍進行比較。

注意
當完整情境改變了優先順序或安全性時，不要僅根據一個單獨的線索選擇行動。

## 重要概念

- **糖尿病酮酸中毒** — 一種伴隨酮症、酸中毒和脫水的高血糖急症。
- **等張液體** — 滲透壓與血漿相似的靜脈輸液，用於支持血管內容積。
- **低灌注** — 組織血流不足。

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