— 生理適應 · EASY · MCQ —
一位第一型糖尿病患者被發現昏迷。患者皮膚冷濕且心跳為 110 次/分。護理師應首先採取什麼行動？
A client with type 1 diabetes mellitus is found unconscious. The client's skin is cold and clammy, and the heart rate is 110 bpm. What should the nurse do first?
- ACheck the client's blood glucose level測量病人的血糖值
- BAdminister 15g of simple carbohydrates orally口服給予 15g 簡單碳水化合物
- CObtain a 12-lead ECG取得十二導程心電圖
- DAdminister 1 mg of glucagon intramuscularly✓ 正解肌肉注射 1 mg 升糖素
— Explanation · 中文詳解 —
患者出現低血糖典型徵象（冷汗、心悸）且已失去意識。對於昏迷患者，嚴禁口服給藥（A 錯，防吸入性肺炎）。若無法立即建立靜脈管道，應首選肌肉注射升糖素（Glucagon）或靜脈注射高濃縮葡萄糖（D50W）。A 雖正確但若症狀緊急應先處理，NCLEX 邏輯中「昏迷+低血糖徵象」需先救命。
An unconscious client with signs of hypoglycemia requires immediate intervention to prevent brain damage. Since oral intake is unsafe due to aspiration risk, intramuscular glucagon is the appropriate emergency treatment when IV access is not yet established.
✦ 台美臨床差異
美國強調護理師在緊急情況下依 protocol 給予 Glucagon；台灣通常需醫師開立醫囑或依急診流程處理。