— 生理適應 · EASY · MCQ —
一位糖尿病病人血糖為 45 mg/dL。護理師應優先採取何種措施？
A client with diabetes mellitus has a finger-stick blood glucose of 45 mg/dL. Which action should the nurse take first?
- ACheck the blood glucose again in 30 minutes30分鐘後再次測量血糖
- BAdminister subcutaneous insulin給予皮下注射胰島素
- CGive 15g of fast-acting carbohydrates✓ 正解給予15克快速作用的碳水化合物
- DNotify the physician通知醫師
— Explanation · 中文詳解 —
血糖 45 mg/dL 為嚴重低血糖。首要任務是提升血糖，給予 15g 快醣（如糖果、果汁）是臨床標準的第一步（15/15 規則）。之後應每 15 分鐘重新檢測。B 會導致血糖更低，D 在處理完緊急低血糖後才需要。
A blood glucose of 45 mg/dL constitutes severe hypoglycemia. The first priority is to raise the blood glucose, and administering 15 g of fast-acting carbohydrate (e.g., candy or juice) is the clinical standard first step (the 15/15 rule). The blood glucose should then be rechecked every 15 minutes. Option B would further lower the blood glucose, and Option D is performed only after the acute hypoglycemic episode is corrected.
✦ 台美臨床差異
美國護理師依 protocol 給糖不需醫師事前同意；台灣臨床仍習慣先告知醫師或按單位 protocol 執行。