— 生理適應 · EASY · MCQ —
糖尿病患者意識不清，血糖 45 mg/dL。護理師應立即採取何種行動？
A client with diabetes mellitus is found unconscious with a blood glucose of 45 mg/dL. Which action should the nurse take immediately?
- AAdminister 50% dextrose intravenously✓ 正解靜脈給予 50% 葡萄糖
- BGive oral orange juice給予口服柳橙汁
- CObtain an ECG取得心電圖
- DAdminister subcutaneous insulin皮下注射胰島素
— Explanation · 中文詳解 —
嚴重低血糖（血糖 < 50 mg/dL）伴隨意識喪失時，病人無法安全吞嚥，口服途徑有窒息風險。此時應建立靜脈通路給予高濃度葡萄糖溶液，快速提升血糖以保護腦部功能。其他選項如胰島素會加重低血糖，ECG 為診斷心臟問題而非首要治療，果汁則不適用於無意識患者。
An unconscious client with severe hypoglycemia cannot safely swallow, making oral administration of glucose risky due to aspiration. The immediate priority is to restore blood glucose levels to protect brain function by administering intravenous 50% dextrose. Insulin would worsen the condition, and obtaining an ECG is not the priority in an acute hypoglycemic crisis.
✦ 台美臨床差異
美台臨床皆以 IV D50W 為主，但在台灣急診室護理師常需醫師口頭醫囑或緊急授權方可執行。