— 生理適應 · EASY · MCQ —
一位病人因低血容性休克入院，下列哪項護理措施為最高優先級？
A client is admitted with hypovolemic shock. Which nursing intervention is the highest priority?
- AAdminister pain medication給予止痛藥
- BInsert a Foley catheter插入導尿管
- CPerform a comprehensive neurological exam進行全面的神經系統評估
- DEstablish two large-bore IV access sites✓ 正解建立兩條大號靜脈通路
— Explanation · 中文詳解 —
低血容性休克的核心問題是循環血量不足，首要目標為恢復灌流。建立兩條大號管徑靜脈通路（Large-bore IVs）是為了能快速輸入大量晶體液或血液製品。插尿管可評估尿量（次要），止痛與神經評估雖重要，但必須在血液動力學穩定後優先處理。
The core problem in hypovolemic shock is insufficient circulating volume, and the primary goal is restoration of perfusion. Establishing two large-bore IVs allows rapid administration of large volumes of crystalloid or blood products. Inserting a urinary catheter is used to assess urine output (secondary), and while pain control and neurologic assessment are important, they must follow restoration of hemodynamic stability.
✦ 台美臨床差異
台灣急診與 ICU 護理師在休克時會迅速執行醫師口頭醫囑建立管路，美式護理強調自主決策快速備妥設備。