護理師照顧一名患有第一型糖尿病的病患，發現其無反應、皮膚濕冷。優先行動為何？
A nurse is caring for a client with Type 1 Diabetes Mellitus who is unresponsive, cold, and clammy. What is the priority action?
- ACheck the client's blood glucose level測量病人的血糖水平
- BAdminister 1 mg of glucagon intramuscularly✓ 正解肌肉注射1 mg的升糖素
- CCall the hospital emergency response team呼叫醫院緊急應變小組
- DProvide 15 grams of simple carbohydrates orally口服提供15克簡單碳水化合物
病患出現意識喪失、皮膚濕冷（Cold and Clammy），高度懷疑為嚴重低血糖休克。在病患無法吞嚥（Unresponsive）的情況下，口服給糖（D）有吸入性肺炎的風險，因此禁用。此時應立即給予升糖素（Glucagon）肌肉注射或 50% 葡萄糖液（D50W）靜脈推注。雖然檢查血糖（A）可確認診斷，但在顯著症狀與意識喪失面前，延遲給糖可能造成不可逆的腦部損傷。NCLEX 指引強調，若無法立即測量血糖，應先視為低血糖處理。呼叫急救小組（C）可在給藥同時進行，但給予升糖藥物是護理師應立即執行的處置。
The client presents with loss of consciousness and cold, clammy skin, raising strong suspicion of severe hypoglycemic shock. With the client unresponsive, oral glucose administration (D) carries a risk of aspiration pneumonia and is therefore contraindicated. The immediate action is to give glucagon intramuscularly or 50% dextrose in water (D50W) by IV push. Although a blood-glucose check (A) can confirm the diagnosis, delaying glucose administration in the presence of obvious symptoms and unconsciousness may cause irreversible brain injury. NCLEX guidelines emphasize that if blood glucose cannot be measured immediately, the situation should be managed as hypoglycemia. Activating the rapid-response team (C) can be done concurrently while medication is given, but administering glucose-raising medication is the action the nurse must implement immediately.
美國 NCLEX 實務中，對於低血糖的處置有明確的「15-15 法則」，但針對昏迷病人則強調 IV D50W 或 IM Glucagon；台灣醫院多有 Standing order 允許護理師在血糖低於特定值且病人昏迷時直接推注 D50W。