— 生理適應 · EASY · MCQ —
一位糖尿病病患表現混亂且冒冷汗。護理師測得末梢血糖值為 45 mg/dL。護理師應先採取何種行動？
A client with diabetes mellitus is found confused and diaphoretic. The nurse immediately assesses a capillary blood glucose of 45 mg/dL. What should the nurse do first?
- ACheck the client's vital signs測量個案的生命徵象。
- BAdminister 15 grams of rapid-acting carbohydrates✓ 正解給予 15 公克的快速作用碳水化合物。
- CAdminister an injection of glucagon注射昇糖素（glucagon）。
- DCall the physician for a stat order聯繫醫師以獲取立即醫囑。
— Explanation · 中文詳解 —
當清醒且具吞嚥能力的低血糖病患出現症狀時，首要護理介入是補充快速吸收碳水化合物（15克）。這能迅速提升血糖以改善意識狀態，避免神經損傷。 glucagon 僅在病人昏迷或無法口服時使用，不應作為首選。
For a conscious, swallow-capable hypoglycemic client, the first intervention is to give 15 grams of rapid-acting carbohydrates. This quickly raises blood glucose to improve mental status and prevent neurological damage. Glucagon is reserved for clients who are unconscious or cannot swallow and is not the first choice here.
✦ 台美臨床差異
美國護理師多有 Standing Order 可執行低血糖流程；台灣護理師亦可依護理常規給予口服糖水或注射，但常需補記醫師醫囑。