— 生理適應 · EASY · MCQ —
一位第一型糖尿病患被發現意識不清且冒冷汗，護理師應優先執行下列哪項處置？
A client with type 1 diabetes mellitus is found unconscious and diaphoretic. Which nursing action is the highest priority?
- ACheck capillary blood glucose✓ 正解測量毛細血管血糖
- BInitiate IV access for hydration建立靜脈通路以補充水分
- CAdminister subcutaneous insulin給予皮下胰島素
- DAdminister intramuscular glucagon給予肌肉注射昇糖素
— Explanation · 中文詳解 —
面對意識改變且冒冷汗的糖尿病病患，首先必須確診是否為低血糖休克。血糖檢查是確認病因的關鍵步驟。在獲得數據前，盲目給予昇糖素或胰島素均有風險。若血糖過低導致意識不清，應優先建立靜脈路徑給予 D50W 靜脈推注；若無法建立路徑，才考慮肌肉注射昇糖素。
When a client with type 1 diabetes is unconscious and diaphoretic, the highest priority is to check capillary blood glucose to confirm hypoglycemia before administering treatment. Administering insulin would be dangerous, and while glucagon or IV dextrose may be needed, verifying the blood sugar level first ensures appropriate and safe intervention.
✦ 台美臨床差異
美國護理師依據 Standing Order 可直接執行血糖檢測及處置，台灣則通常需先確認醫囑或依據急救流程先行檢測再回報醫師。