— 生理適應 · EASY · MCQ —
一位第一型糖尿病病人被發現意識不清、臉色蒼白且冒冷汗。護理師的優先處置為何？
A client with type 1 diabetes mellitus is found unconscious, pale, and diaphoretic. What is the nurse's priority action?
- AAdminister 15g of fast-acting carbohydrate orally口服給予 15 公克快速作用的碳水化合物
- BAdminister subcutaneous insulin皮下注射胰島素
- CAssess the client's airway✓ 正解評估病人的呼吸道
- DObtain a capillary blood glucose reading測量毛細血管血糖值
— Explanation · 中文詳解 —
護理優先順序遵循 ABC 原則（Airway, Breathing, Circulation）。意識不清的病人無法保護呼吸道，且若低血糖發生時個案伴隨嘔吐，極易導致吸入性肺炎。因此，確保呼吸道通暢（Assess airway）是第一優先。在確認呼吸道安全後，再依序評估生命徵象並執行血糖檢測與相應處理。
Following the ABCs of nursing care, assessing and protecting the airway is the priority for an unconscious client to prevent aspiration. Oral carbohydrates are unsafe due to the risk of choking, and while glucose assessment is necessary, airway patency must be ensured first.