# 一名護理師正照護一位意識清楚的第1型糖尿病成年個案。個案於早晨胰島素注射後30分鐘出現顫抖、出汗及心悸。床邊毛細血糖為52 mg/dL。護理師應優先採取下列何項措施?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=360524&lang=zh-tw  
> language: zh-TW  
> subject: Medical Emergencies  
> category: PA

## 題目

一名護理師正照護一位意識清楚的第1型糖尿病成年個案。個案於早晨胰島素注射後30分鐘出現顫抖、出汗及心悸。床邊毛細血糖為52 mg/dL。護理師應優先採取下列何項措施?

## 選項

1. 給予15 g速效性口服碳水化合物(如果汁4 oz),並於15分鐘後重測血糖 **✔ 正確答案**
2. 立即通知主要照護提供者，記錄事件，並持續監測個案的生命徵象
3. 皮下注射 1 mg glucagon，然後在 15 分鐘後重新檢查血糖，並通知醫療提供者
4. 暫停下一餐常規餐點，直到血糖恢復正常，以防止反彈性高血糖

**正確答案: 1**

## 解析

15法則(15 g速效性口服碳水化合物→15分鐘後重測血糖)是意識清楚、可吞嚥的成人症狀性低血糖之第一線處置。升糖素僅用於意識喪失、抽搐或無法經口攝食之個案。通知醫師宜於穩定後執行,非首要動作。暫停飲食將加重低血糖,與建議相反。

## 深入解析

Clinical Judgment
關鍵線索是意識清楚+神經低糖症狀及交感神經症狀+BG 52 mg/dL。Recognize Cues(意識清楚個案之輕中度低血糖)→Analyze Cues(ADA準則:清醒時優先口服葡萄糖)→Take Action(套用15法則)。

Memory Tip
「15-15法則」:15 g碳水化合物→15分鐘後重測。仍

## 臨床情境

Clinical Practice Guide
意識清楚的症狀性低血糖(

## 重要概念

- **Hypoglycemia(低血糖)** — 血糖
- **15法則(Rule of 15)** — ADA建議之意識清楚輕中度低血糖處置流程:15 g速效性口服碳水化合物→15分鐘後重測血糖→仍
- **Glucagon(升糖素)** — 胰α細胞荷爾蒙,於無法經口攝食之重度低血糖個案以IM或SC 1 mg給予,藉分解肝醣升高血糖。常見副作用為噁心嘔吐,需採側臥復原姿勢。

## 相同主題題目

- [A 68-year-old client with COPD is admitted with shortness of breath and SpO2 86% on room a…](https://mymerci.kr/pages/nclex_q.php?qn_id=362940&lang=zh-tw)
- [A 58-year-old client arrives at the emergency department with crushing substernal chest pa…](https://mymerci.kr/pages/nclex_q.php?qn_id=362976&lang=zh-tw)
- [A 72-year-old client is brought to the emergency department by family who report that the …](https://mymerci.kr/pages/nclex_q.php?qn_id=363003&lang=zh-tw)
- [A 79-year-old client is admitted from a long-term care facility with diarrhea, decreased o…](https://mymerci.kr/pages/nclex_q.php?qn_id=363089&lang=zh-tw)
- [A nurse is caring for a client prescribed Digoxin. Which nursing action is most appropriat…](https://mymerci.kr/pages/nclex_q.php?qn_id=375157&lang=zh-tw)
- [Which action should the nurse take?](https://mymerci.kr/pages/nclex_q.php?qn_id=391869&lang=zh-tw)
- [A client with type 1 diabetes is awake, can swallow, and reports shakiness. The point-of-c…](https://mymerci.kr/pages/nclex_q.php?qn_id=393564&lang=zh-tw)
- [A client develops wheezing, generalized hives, and blood pressure 78/42 mm Hg after receiv…](https://mymerci.kr/pages/nclex_q.php?qn_id=393725&lang=zh-tw)

## 以其他語言閱讀

- [en](https://mymerci.kr/pages/nclex_q.php?qn_id=360524&lang=en)
- [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=360524&lang=ko)
- [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=360524&lang=ja)
- [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=360524&lang=zh-tw)
- [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=360524&lang=vi)

---

More free questions: [NCLEX-RN 題庫](https://mymerci.kr/pages/nclex_bank.php?lang=zh-tw)

_僅供學習參考。實際臨床請遵循最新指引與所屬機構規範。_