— 藥理與非經腸給藥 · HARD · SATA —
接班後，下列哪位病人應優先進行評估？（選所有適合的）
Which of the following clients should the nurse prioritize for assessment after receiving a report? (Select all that apply.)
- AA client receiving IV vancomycin reporting facial flushing✓ 正解接受靜脈注射萬古黴素並報告面部潮紅的病人
- BA client on heparin drip with an aPTT of 80 seconds使用肝素靜脈滴注且 aPTT 為 80 秒的病人
- CA client receiving morphine PCA reporting pruritus接受嗎啡 Patient-Controlled Analgesia (PCA) 並報告搔癢的病人
- DA client on digoxin with a potassium level of 3.2 mEq/L✓ 正解血鉀濃度為 3.2 mEq/L 且服用地高辛的病人
- EA client receiving IV magnesium sulfate for pre-eclampsia with absent deep tendon reflexes✓ 正解因子癇前症接受靜脈注射硫酸鎂且深層肌腱反射消失的病人
— Explanation · 中文詳解 —
需優先評估的個案包括：A（紅人症候群需減速，嚴重可能過敏）、D（低血鉀會增加毛地黃毒性風險）、E（深層肌腱反射消失為鎂中毒徵兆）。B 的 aPTT 雖然略高但屬治療範圍邊緣，C 的搔癢為鴉片類常見副作用，相對不緊急。
Clients requiring priority assessment include: A (red man syndrome requires slowing the infusion and may indicate severe allergy), D (hypokalemia increases the risk of digitalis toxicity), and E (loss of deep tendon reflexes is a sign of magnesium toxicity). The aPTT in B is slightly high but at the upper edge of the therapeutic range, and the itching in C is a common opioid side effect that is relatively non-urgent.
✦ 台美臨床差異
台灣臨床對 Magnesium sulfate 的監測頻率要求極高，護理師需在床邊備有 Calcium gluconate。