— 照護管理 · HARD · MCQ —
護理師照顧病人時，病人突發胸痛，應優先採取何種措施？
A nurse is caring for a client who is experiencing a sudden onset of chest pain. Which action should the nurse take first?
- AAssess the client's vital signs✓ 正解評估病人的生命徵象
- BAdminister sublingual nitroglycerin給予舌下硝酸甘油
- CApply oxygen via nasal cannula經鼻導管給氧
- DObtain a 12-lead ECG進行十二導程心電圖檢查
— Explanation · 中文詳解 —
面對急性胸痛，首要任務是評估生命徵象（ABC 評估的一部分），確認血流動力學穩定度。雖然氧氣與心電圖很重要，但若不先了解血壓（尤其是使用 Nitroglycerin 前必須測量血壓以防休克），貿然用藥風險極高。穩定病況優先於診斷。
When confronted with acute chest pain, the priority is to assess vital signs (part of the ABC assessment) and confirm hemodynamic stability. Although oxygen and ECG are important, administering medication without first knowing the blood pressure (especially before using nitroglycerin, where blood pressure must be measured to prevent shock) carries extreme risk. Stabilizing the client takes priority over diagnostics.
✦ 台美臨床差異
美台臨床對於胸痛處置流程一致，皆強調給藥前的血壓評估。