— 生理適應 · EASY · MCQ —
一位糖尿病患者正接受規則胰島素治療，護理師觀察到其皮膚濕冷、盜汗且有震顫。下列何者為優先處置？
A client with diabetes mellitus is receiving regular insulin. The nurse observes the client has cool, clammy skin, diaphoresis, and tremors. Which action is the priority?
- ACall the physician immediately立即聯絡醫師
- BCheck the client's blood glucose level✓ 正解測量病人的血糖水平
- CAdminister an extra dose of insulin給予額外的胰島素劑量
- DPerform a physical assessment of neurological signs進行神經學徵兆的身體評估
— Explanation · 中文詳解 —
病人的症狀（冷汗、震顫）顯示出現低血糖。護理優先順序為確認血糖數值（Assessment）後，再進行處置（如給予糖水）。不可盲目給予胰島素，否則會加劇低血糖引發昏迷。評估神經徵象重要但非首務，通知醫師前應先取得血糖數據以利回報。
The client's symptoms of cool, clammy skin, diaphoresis, and tremors are classic signs of hypoglycemia. The nurse's first action should be to check the blood glucose level to confirm the diagnosis before intervening. Administering more insulin would worsen the condition, and while notifying the provider is necessary, assessment data must be obtained first.
✦ 台美臨床差異
美台臨床皆視低血糖為緊急事件，護理師依 protocol 執行採血與給糖，無需等待醫囑。