一位病人出現低血糖症狀（血糖值 55 mg/dL）。護理師應執行哪些介入措施？（選所有適合的）
A client is experiencing symptoms of hypoglycemia (BS 55 mg/dL). Which interventions should the nurse perform? (Select all that apply.)
- AAdminister 15g of rapid-acting carbohydrates✓ 正解給予 15g 快速作用的碳水化合物
- BAdminister intramuscular glucagon if the client is unconscious✓ 正解若病人意識不清，則給予肌肉注射升糖素
- CRecheck blood glucose in 15 minutes✓ 正解15 分鐘後重新測量血糖
- DProvide a high-fat snack to maintain blood glucose提供高脂肪零食以維持血糖
- EAssess for tachycardia and diaphoresis✓ 正解評估是否有心搏過速和盜汗
處理低血糖遵循「15-15 法則」。對於清醒病人，給予 15 克快速吸收碳水化合物（如葡萄糖液、果汁），15 分鐘後重新監測。若意識喪失，必須考慮給予肌肉注射升糖素或靜脈注射 D50W，因為口服會增加誤吸風險。同時，必須評估病人的交感神經反應（如心跳加快、冒冷汗），這是身體對抗低血糖的典型生理回應。高脂肪食物（如巧克力、花生醬）因脂肪會延緩碳水化合物的吸收，不適合作為低血糖急性期的處置，因為會造成血糖上升延遲。此類處置的核心在於恢復腦部灌流與代謝平衡，並嚴防再度低血糖發作。
The management of hypoglycemia follows the "15-15 rule." In a conscious client, 15 grams of rapidly absorbable carbohydrate (such as glucose solution or fruit juice) is given, and the blood glucose is rechecked after 15 minutes. If the client is unconscious, intramuscular glucagon or intravenous D50W must be considered, because oral administration increases the risk of aspiration. The nurse must also assess the client's sympathetic responses (such as tachycardia and diaphoresis), which represent the body's typical physiologic response to hypoglycemia. High-fat foods (such as chocolate or peanut butter) are not appropriate during acute hypoglycemia, because the fat delays carbohydrate absorption and causes a delayed rise in blood glucose. The focus of management is to restore cerebral perfusion and metabolic balance and to strictly guard against recurrence of hypoglycemia.
美國護理指引高度強調床邊護理師的自主權，可依據低血糖 Protocol 直接給予治療；台灣醫院較為嚴格，通常給予 D50W 需醫師開立醫囑，雖然緊急情況下護理師可先給予口服糖水並報告，但靜脈給藥的處置權限範圍較小。