— 生理適應 · MEDIUM · SATA —
一位第一型糖尿病患被發現昏迷，下列哪些護理措施是適當的？（選所有適合的）
A client with type 1 diabetes mellitus is found unconscious. What nursing actions are appropriate? (Select all that apply.)
- ACheck blood glucose level immediately✓ 正解立即測量血糖值
- BAdminister oral orange juice給予口服柳橙汁
- CPrepare to administer IV dextrose✓ 正解準備給予靜脈注射葡萄糖
- DAssess airway patency✓ 正解評估呼吸道通暢度
- EAssess for signs of dehydration評估脫水跡象
— Explanation · 中文詳解 —
面對意識不清的糖尿病患，首要確認是否為低血糖休克。護理師需確保呼吸道通暢，立即測量血糖；若血糖極低且無法吞嚥，不可給予口服（避免吸入性肺炎），必須靜脈注射葡萄糖水。脫水評估為後續步驟，非緊急急救重點。
For an unconscious client with type 1 diabetes, the nurse must first assess airway patency and immediately check blood glucose levels to confirm hypoglycemia. If hypoglycemia is confirmed, IV dextrose should be prepared and administered, as oral intake is contraindicated due to the risk of aspiration.
✦ 台美臨床差異
美國護理師在確認低血糖後多可依協定給藥；台灣護理師通常需醫師評估後，由醫師指示給予靜脈葡萄糖。