— 生理適應 · EASY · MCQ —
一位糖尿病患被發現意識不清，血糖值為 45 mg/dL。護理師應優先執行哪項措施？
A client with diabetes mellitus is found unconscious with a blood glucose level of 45 mg/dL. Which action should the nurse implement first?
- AAdminister subcutaneous insulin給予皮下注射胰島素
- BAdminister 50% dextrose intravenously✓ 正解靜脈注射50%葡萄糖
- CPerform a neurological assessment進行神經學評估
- DProvide orange juice by mouth經口提供柳橙汁
— Explanation · 中文詳解 —
低血糖導致的意識喪失屬於急症。由於病人意識不清，無法經口攝取葡萄糖，必須透過靜脈途徑給予 50% 葡萄糖液以快速提升血糖。A 選項會導致血糖更低；D 選項恐造成吸入性肺炎；C 選項雖然重要，但必須在優先恢復生理穩定後進行。
For an unconscious client with severe hypoglycemia, administering intravenous 50% dextrose is the priority to rapidly correct low blood glucose levels. Oral intake is contraindicated due to aspiration risk, and insulin would worsen the condition, while assessment must follow immediate stabilization.
✦ 台美臨床差異
美台臨床對於急診低血糖處置均依循 ACLS/ADA 指引，差異不大。