— 生理適應 · EASY · MCQ —
一位糖尿病病人被發現意識不清，血糖值為 45 mg/dL。護理師應優先執行下列哪項措施？
A client with diabetes mellitus is found unconscious with a blood glucose of 45 mg/dL. Which action should the nurse perform first?
- AAdminister glucagon intramuscularly肌肉注射升糖素
- BAdminister 50% dextrose IV push✓ 正解靜脈推注50%葡萄糖
- CGive 15g of rapid-acting carbohydrates orally口服給予15克快速作用碳水化合物
- DRecheck the blood glucose level重新測量血糖值
— Explanation · 中文詳解 —
針對意識不清的低血糖病人，首要之務是提升血管內血糖值，以改善腦部缺糖狀況。因病人意識不清，不可給予口服食物以免造成吸入性肺炎。若已有 IV 管路，靜脈注射 50% Dextrose 是最快途徑；若無管路則優先考慮肌肉注射升糖素。
For an unconscious client with hypoglycemia, the first priority is to raise intravascular glucose in order to relieve cerebral glucose deprivation. Because the client is unconscious, oral intake must not be given due to the risk of aspiration. If IV access is available, IV push of 50% dextrose is the fastest route; if no IV access is available, intramuscular glucagon is the next option.
✦ 台美臨床差異
美國醫院常見 Protocol 下護理師可直接給予 D50；台灣臨床多需先與醫師確認或依據特定的護理常規執行。