護理師發現給藥錯誤，病人接受了兩倍劑量的胰島素。護理師應優先採取的行動為何？

發生給藥錯誤（Medication error）時，護理師的首要職責是確保病人安全（Patient safety）。這遵循臨床應變的「ABC 原則」精神，即「Airway, Breathing, Circulation」的延伸，將病人安全置於最高優先。核心概念是評估病人當前的生理狀況，判斷錯誤是否已造成即時的傷害，並採取必要的補救措施。 正確答案 B 是最優先的步驟。給予病人兩倍劑量的胰島素（Insulin）可能導致嚴重的低血糖（hypoglycemia）。低血糖會影響腦部功能，嚴重時可能導致意識喪失、癲癇甚至死亡。因此，護理師必須立即評估病人的生命徵象（Vital signs）和血糖值（Blood glucose level），以確認病人是否出現低血糖症狀，並根據評估結果及時給予葡萄糖或其他昇糖處理，防止病情惡化。 選項 C（完成事件報告）和 A（通知主管）是後續的行政與品質改善步驟。雖然這些步驟也非常重要，但它們必須在確保病人生命安全之後進行。報告錯誤有助於分析原因、預防再發，但不能取代對病人的即時臨床照護。選項 D（聯繫醫師）也是必要步驟，但通常是在初步評估病人狀況並採取緊急措施後進行，除非病人情況極度危急且護理師無法立即處理。在大多數情況下，護理師有能力和責任先進行初步評估與穩定病人。

When a medication error occurs, the nurse's primary responsibility is to ensure patient safety. This follows the spirit of the clinical 'ABC principle' (Airway, Breathing, Circulation), placing patient safety at the highest priority. The core concept is to assess the client's current physiologic status, determine whether the error has caused immediate harm, and take necessary corrective action. The correct answer B is the most prioritized step. Administering double the prescribed dose of insulin may cause severe hypoglycemia, which can impair brain function and, in severe cases, lead to loss of consciousness, seizures, or even death. Therefore, the nurse must immediately assess the client's vital signs and blood glucose level to confirm whether the client is showing symptoms of hypoglycemia and provide glucose or other corrective treatment in a timely manner based on the assessment to prevent deterioration. Option C (completing an incident report) and option A (notifying the manager) are subsequent administrative and quality-improvement steps. While these are also very important, they must occur after the client's life safety has been ensured. Reporting the error helps analyze causes and prevent recurrence, but cannot replace immediate clinical care for the client. Option D (calling the physician) is also necessary but is generally performed after an initial assessment of the client and emergency measures have been taken, unless the situation is extremely critical and the nurse is unable to manage it. In most cases, the nurse has the ability and responsibility to first perform an initial assessment and stabilize the client.