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一位第一型糖尿病患出現冒冷汗、震顫及意識混亂。護理師應採取哪些行動?(選所有適合的)

A client with diabetes mellitus type 1 exhibits diaphoresis, tremors, and confusion. Which actions should the nurse perform? (Select all that apply.)

  • AAdminister 15g of fast-acting carbohydrates✓ 正解
    給予15克快效碳水化合物
  • BCheck capillary blood glucose level✓ 正解
    檢查毛細管血糖值
  • CAdminister insulin to prevent hyperglycemia
    給予胰島素以防止高血糖
  • DAssess the client's ability to swallow✓ 正解
    評估病人的吞嚥能力
  • ERecheck blood glucose in 15 minutes✓ 正解
    15分鐘後重新檢查血糖
Explanation · 中文詳解

第一型糖尿病病人出現冒冷汗、震顫及意識混亂,這是典型的低血糖(Hypoglycemia)症狀。根據 NCLEX 安全護理原則,應立即確認血糖值(Check glucose),若確認低血糖,則給予 15g 快效碳水化合物,隨後評估吞嚥能力以防嗆咳,並在 15 分鐘後重新評估血糖。嚴禁給予胰島素,以免低血糖惡化。

A client with type 1 diabetes who presents with cold sweats, tremors, and confusion is showing classic signs of hypoglycemia. According to NCLEX safety principles, the nurse should immediately check the blood glucose. If hypoglycemia is confirmed, 15 g of fast-acting carbohydrate should be administered, and the client's swallowing ability should then be evaluated to prevent aspiration. Blood glucose should be rechecked 15 minutes later. Insulin must not be administered, as this would worsen the hypoglycemia.

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