— 生理適應 · EASY · MCQ —
一位第一型糖尿病病人被發現意識不清、盜汗且顫抖。護理師首要介入為何？
A client with type 1 diabetes is found unresponsive, diaphoretic, and shivering. What is the nurse's priority intervention?
- AAdminister subcutaneous insulin皮下注射胰島素
- BAdminister intravenous dextrose✓ 正解靜脈注射葡萄糖
- CProvide oral orange juice提供口服柳橙汁
- DCheck capillary blood glucose測量指尖血糖
— Explanation · 中文詳解 —
病人已出現意識改變，為低血糖重症表現。此時不宜給予口服（有嗆入風險），應立即建立靜脈通道並給予葡萄糖液。Subcutaneous insulin 會加重低血糖。檢查血糖雖然重要，但在已出現意識喪失下，臨床處置應以挽救生命之給糖為先。
The client is exhibiting signs of severe hypoglycemia with unresponsiveness, requiring immediate life-saving intervention. Intravenous dextrose is the priority treatment because oral administration is unsafe due to aspiration risk, and subcutaneous insulin would worsen the condition. Although checking blood glucose is important, the nurse must act to reverse the hypoglycemic state immediately when the patient is unresponsive.
✦ 台美臨床差異
美國急診護理師依流程可先行給糖；台灣通常仍需醫師確認或根據醫囑開立之緊急常規給藥。