— 生理適應 · EASY · MCQ —
一位第一型糖尿病患被發現意識不清。血糖值為 35 mg/dL。護理師應優先採取哪項行動？
A client with type 1 diabetes is found unconscious and unresponsive. The bedside glucose level is 35 mg/dL. Which action should the nurse take first?
- AAdminister IV Dextrose 50% as ordered✓ 正解依醫囑給予 50% 葡萄糖靜脈注射
- BAdminister orange juice orally口服柳橙汁
- CCall the rapid response team呼叫快速反應小組
- DCheck vital signs測量生命徵象
— Explanation · 中文詳解 —
病患意識不清，給予口服糖水（選項 B）具有極高誤吸風險。立即處理低血糖需透過靜脈途徑給予高濃度葡萄糖（D50W）。呼叫醫療團隊（選項 C）雖然需要，但在護理師已確認血糖並準備藥物的情況下，建立靜脈通路給藥是當下挽救意識的關鍵。
Because the client is unconscious, oral administration of glucose is contraindicated due to the high risk of aspiration. The priority intervention is to rapidly correct severe hypoglycemia by administering intravenous dextrose 50% as ordered, which serves as the definitive treatment for this emergency.
✦ 台美臨床差異
台灣護理師執行 D50W 給藥通常需醫師當下醫囑，但在緊急狀況下依據院內 Protocol 可先行處置。