# 一位意識清醒的糖尿病個案主訴發抖和出汗。血糖值為 58 mg/dL。護理師應採取哪項行動？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=397150&lang=zh-tw  
> language: zh-TW  
> subject: Illness Management  
> category: PA

## 題目

一位意識清醒的糖尿病個案主訴發抖和出汗。血糖值為 58 mg/dL。護理師應採取哪項行動？

## 選項

1. 給予預定的長效胰島素。
2. 讓個案維持禁食狀態。
3. 等待 1 小時後重新檢測血糖。
4. 給予 15 公克的速效碳水化合物。 **✔ 正確答案**

**正確答案: 4**

## 解析

意識清醒的輕度低血糖個案應接受速效碳水化合物，通常為 15 公克，之後再重新評估。給予胰島素會使低血糖惡化。等待會延誤治療，而在個案能安全吞嚥時，禁食狀態並不適當。

## 深入解析

臨床判斷
運用個案線索、時間點、檢驗數據及安全風險，選擇最適合「意識清醒的低血糖個案」情境的回應。

記憶提示
將最強的線索群與最安全的護理判斷配對。

KR vs US
NCLEX 考題獎勵基於線索的優先思考，而非單獨的記憶提取。

## 臨床情境

臨床實務指引
針對「意識清醒的低血糖個案」，將完整的線索模式與個案當前的穩定性、醫囑數據及預期的護理範圍進行比較。

注意事項
當完整情境改變了優先順序或安全性時，切勿僅根據單一線索選擇行動。

## 重要概念

- **低血糖** — 血糖值低於預期範圍，可能引起腎上腺素性和神經學症狀。
- **速效碳水化合物** — 一種快速吸收的碳水化合物，用於升高血糖。
- **重新評估** — 在介入措施後進行的追蹤評估，以判斷反應。

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