— 生理適應 · EASY · MCQ —
糖尿病患者被發現昏迷，血糖值為 42 mg/dL。護理師應採取的最優先行動為何？
A client with diabetes mellitus is found unconscious with a blood glucose level of 42 mg/dL. Which nursing action is the priority?
- APerform a neurological assessment進行神經學評估
- BGive 4 ounces of orange juice給予4盎司柳橙汁
- CCall the physician immediately立即通知醫師
- DAdminister 50% dextrose IV push✓ 正解靜脈推注50%葡萄糖
— Explanation · 中文詳解 —
對於意識不清、無法口服攝取糖分的低血糖病人，給予 IV 葡萄糖是恢復意識最快的方式。口服果汁（選項 B）可能導致吸入性肺炎，且昏迷時病人無法吞嚥。通知醫師與神經評估雖為必要，但在低血糖導致的腦部缺糖急症中，建立血糖穩定度優先於報告。
In an unconscious client with severe hypoglycemia, intravenous administration of 50% dextrose is the priority to rapidly restore blood glucose levels. Oral intake is contraindicated due to the high risk of aspiration, and while assessment and notification are necessary, immediate physiological stabilization takes precedence.
✦ 台美臨床差異
美國護理師依醫囑執行 IV Dextrose，台灣則常見由醫師親自操作給藥。