— 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 42 mg/dL。護理師應優先採取哪項措施？
A client with type 1 diabetes is found unresponsive with blood glucose at 42 mg/dL. Which action should the nurse take first?
- AAssess airway patency and breathing✓ 正解評估呼吸道通暢性及呼吸狀況
- BGive 15g of simple carbohydrates orally口服給予15克簡單碳水化合物
- CAdminister 50% dextrose IV push靜脈推注給予50%葡萄糖
- DAdminister subcutaneous glucagon皮下注射升糖素
— Explanation · 中文詳解 —
NCLEX 考試中，面對意識不清（unresponsive）的病人，必須嚴格遵循 ABC（Airway, Breathing, Circulation）原則。病人若意識不清，保護呼吸道通暢（airway patency）是首要任務，因為病人可能因嘔吐導致吸入性肺炎或呼吸道阻塞。在確保呼吸道安全後，才能進行後續的靜脈給藥治療。
For an unresponsive client, the nurse must prioritize assessing airway patency and breathing according to the ABCs of emergency care to prevent aspiration. Oral carbohydrate administration is contraindicated due to choking risk, while IV dextrose or glucagon should only be administered after ensuring the airway is secure.