— 生理適應 · EASY · MCQ —
一位第一型糖尿病患被發現意識不清，下列哪項處置最優先？
A nurse is caring for a client with type 1 diabetes who is found unconscious. Which action is the priority?
- AAdminister oral orange juice給予口服柳橙汁
- BInitiate IV infusion of normal saline開始靜脈輸注生理食鹽水
- CAssess blood glucose level✓ 正解評估血糖值
- DAdminister subcutaneous insulin給予皮下注射胰島素
— Explanation · 中文詳解 —
意識不清的病人應先確認血糖值（指尖血糖），排除低血糖引起的昏迷。若為低血糖，應立即建立靜脈通路給予 D50W，而非口服果汁（避免吸入性肺炎）。若血糖極高，則需依據醫囑處理 DKA。確認病因是後續救治的基礎。
An unconscious client should first have a fingerstick blood glucose checked to rule out hypoglycemic coma. If hypoglycemia is present, IV access should be established immediately and D50W given, rather than oral juice (to avoid aspiration pneumonia). If the blood glucose is extremely high, DKA should be managed per provider orders. Confirming the cause is the foundation of subsequent treatment.
✦ 台美臨床差異
美國護理單位對昏迷病人執行 Point-of-care testing (POCT) 流程非常明確，台灣亦同，但護理師執行頻率極高。