— 生理適應 · EASY · MCQ —
一位新診斷糖尿病病人出現顫抖、盜汗與意識混亂。護理師應採取的第一步行動為何？
A nurse is caring for a client with a new diagnosis of diabetes mellitus. The client is experiencing shakiness, diaphoresis, and confusion. Which action should the nurse take first?
- AAdminister 15g of fast-acting carbohydrate給予 15g 快速作用的碳水化合物
- BContact the physician for orders聯絡醫師以獲取醫囑
- CAdminister intravenous D50W給予靜脈注射 D50W
- DObtain a capillary blood glucose level✓ 正解測量毛細血管血糖值
— Explanation · 中文詳解 —
糖尿病病人出現顫抖、盜汗、意識混亂，高度懷疑為低血糖（Hypoglycemia）發作。護理師應遵循護理程序（Nursing Process），在介入前先「評估（Assessment）」。透過指尖血糖（Capillary blood glucose）確認數值，能作為後續給予快速吸收醣類或靜脈注射葡萄糖的決策依據，避免在非低血糖情況下盲目治療。
A diabetic client with shakiness, diaphoresis, and confusion is highly suspected of having hypoglycemia. The nurse should follow the nursing process and 'assess' before intervening. Checking a capillary blood glucose value provides the basis for subsequent administration of rapid-acting carbohydrate or IV dextrose, avoiding empiric treatment in cases that may not actually be hypoglycemia.