— 生理適應 · EASY · MCQ —
一位第一型糖尿病病人被發現意識不清、盜汗、心跳加速。護理師應優先採取何種措施？
A client with type 1 diabetes mellitus is found unconscious, diaphoretic, and tachycardic. Which action should the nurse take first?
- AAssess the client's airway and breathing✓ 正解評估病人的呼吸道與呼吸
- BAdminister subcutaneous regular insulin給予皮下注射常規胰島素
- CObtain a capillary blood glucose reading測量指尖血糖值
- DAdminister 50% dextrose IV push靜脈推注 50% 葡萄糖溶液
— Explanation · 中文詳解 —
面對意識不清（Unconscious）的病人，首要任務永遠是評估 ABC（Airway, Breathing, Circulation）。即便臨床高度懷疑是低血糖（Hypoglycemia）導致的意識改變，若呼吸道阻塞或無效呼吸，病人會迅速發生缺氧導致心跳停止。因此，護理師必須先確保呼吸道通暢與呼吸存在，接著才能進行後續的血糖檢測與靜脈注射給藥。
In any unresponsive client, the nurse must prioritize assessing the airway and breathing to prevent hypoxia and cardiac arrest. Although hypoglycemia is suspected, ensuring respiratory safety takes precedence over obtaining a blood glucose reading or administering treatment.