糖尿病患者被發現意識不清，血糖值為 42 mg/dL。護理師應優先採取什麼行動？
A client with diabetes mellitus is found unconscious with a blood glucose level of 42 mg/dL. Which action should the nurse take first?
- ARecheck the blood glucose level重新測量血糖值
- BAdminister glucagon intramuscularly肌肉注射 glucagon
- CAdminister 50% dextrose IV push✓ 正解靜脈推注 50% dextrose
- DProvide 4 ounces of orange juice提供 4 盎司柳橙汁
針對意識不清的低血糖病人，首要原則是「恢復腦部葡萄糖供給」。由於病人意識不清，絕對禁止經口餵食以防誤吸（Aspiration）。臨床上應立即建立靜脈通道給予高濃度葡萄糖（D50W）。若無法立即建立靜脈通道，則使用肌肉注射升糖素（Glucagon）。此情境下，病人的大腦功能正在受損，快速提升血糖是最高優先級（ABC 原則）。
For an unconscious client with hypoglycemia, the primary principle is to restore glucose supply to the brain. Because the client is unresponsive, oral intake is absolutely contraindicated to prevent aspiration. Clinically, IV access should be established immediately to administer a high-concentration dextrose solution (D50W). If IV access cannot be established quickly, intramuscular glucagon should be used. In this scenario, the client's brain function is being compromised, and rapid restoration of blood glucose is the highest priority (ABC principle).
在美國臨床，護理師在執行急救時需具備獨立判斷給藥（如特定 Protocol 下）的權限；台灣臨床環境中，此類處置通常需要醫師立即開立醫囑或依據急救常規（Standing Order）執行。