— 生理適應 · HARD · MCQ —
一位第一型糖尿病患被發現無反應，血糖值為 35 mg/dL。護理師應立即採取什麼行動？
A client with type 1 diabetes is found unresponsive with a blood glucose level of 35 mg/dL. What is the immediate nursing intervention?
- AAdminister subcutaneous insulin給予皮下注射胰島素
- BAdminister orange juice orally口服柳橙汁
- CAdminister 50% dextrose IV push✓ 正解靜脈推注50%葡萄糖
- DCall the physician呼叫醫師
— Explanation · 中文詳解 —
病人已無反應，經口給糖（B）會導致吸入性肺炎，絕對禁止。此為嚴重低血糖，需立即建立靜脈管道給予高濃度葡萄糖（D50W）。 insulin（A）會使血糖更低，通知醫師（D）是次要步驟，應先執行急救處置。
Because the client is unresponsive, oral administration of glucose is contraindicated due to the high risk of aspiration. The immediate priority is to administer intravenous 50% dextrose to rapidly correct severe hypoglycemia and restore consciousness.
✦ 台美臨床差異
美國部分州護理師可依 Protocol 給予 glucagon 或 D50；台灣需醫囑或符合緊急醫療法規。