# 一名糖尿病酮酸血症個案在開始胰島素輸注前，血清鉀為 3.1 mEq/L。護理師應預期採取哪項行動？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=397453&lang=zh-tw  
> language: zh-TW  
> subject: Medical Emergencies  
> category: PA

## 題目

一名糖尿病酮酸血症個案在開始胰島素輸注前，血清鉀為 3.1 mEq/L。護理師應預期採取哪項行動？

## 選項

1. 立即開始胰島素輸注，無需額外醫囑。
2. 根據醫囑，在胰島素治療前或治療中補充鉀。 **✔ 正確答案**
3. 給予 sodium polystyrene sulfonate 以降低鉀離子。
4. 限制所有靜脈輸液，直到鉀離子恢復正常。

**正確答案: 2**

## 解析

胰島素會將鉀離子移入細胞內，可能加劇低血鉀。在糖尿病酮酸血症中，必須根據治療方案，在胰島素治療前或治療中矯正低血鉀，以降低心律不整的風險。在此線索模式下，使用降鉀治療或限制輸液是不安全的。

## 深入解析

臨床判斷
使用個案線索、時間點、檢驗數據和安全風險，選擇最符合 DKA 合併低血鉀的回應。

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，而非孤立的回憶。

## 臨床情境

臨床實務指引
對於 DKA 合併低血鉀，將完整的線索模式與個案當前的穩定性、醫囑數據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，不要僅根據一個孤立的線索選擇行動。

## 重要概念

- **糖尿病酮酸血症** — 一種伴隨酮症、脫水和代謝性酸中毒的高血糖急症。
- **低血鉀** — 血清鉀過低，可能導致肌肉無力和心律不整。
- **胰島素輸注** — 用於治療嚴重高血糖和酮酸血症的連續性靜脈胰島素。

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