— 生理適應 · EASY · MCQ —
一名第一型糖尿病病人被發現意識不清，血糖值為 45 mg/dL。護理師應優先採取何種措施？
A client with type 1 diabetes is found unresponsive with a blood glucose of 45 mg/dL. Which action should the nurse implement first?
- ARecheck the blood glucose level重新測量血糖值
- BProvide a snack of peanut butter crackers提供花生醬餅乾作為點心
- CAssess for a patent airway✓ 正解評估呼吸道是否暢通
- DAdminister 50% dextrose intravenously靜脈注射 50% 葡萄糖溶液
— Explanation · 中文詳解 —
根據 ABC（Airway, Breathing, Circulation）護理優先順序，當病人意識不清時，維持呼吸道通暢（Airway）是最高優先級。低血糖病人昏迷時，口腔內若有異物或舌頭後墜皆可能導致窒息。在確保呼吸道安全前，絕對禁止給予口服糖分，以避免吸入性肺炎，應優先建立靜脈通路給予葡萄糖。
According to the ABC priority framework, ensuring a patent airway is the first step for any unresponsive client to prevent aspiration. Oral intake is contraindicated in unconscious patients, making airway assessment the immediate priority over glucose administration.