病人突然主訴胸痛並放射至左手臂。護理師首要介入為何？
A client presents with a sudden onset of chest pain radiating to the left arm. What is the priority nursing intervention?
- AObtain an EKG✓ 正解取得心電圖
- BAdminister aspirin給予阿斯匹靈
- CAssess vital signs評估生命徵象
- DPlace the client in a semi-Fowler's position將病人置於半坐臥位
面對突發胸痛放射至左臂的疑似 ACS（急性冠心症）情境，依 NCLEX/AHA 2024 指引，優先處置順序為：取得 12 導程心電圖（A）以判斷是否 STEMI 與心律是否異常 → 評估生命徵象與血氧 → 給予阿斯匹靈、舌下硝酸甘油等。半坐臥位 (D) 雖能減輕心臟負擔屬於支持性處置，但無法取代立即診斷動作；姿勢調整應在診斷與評估同時進行，但「優先動作」是 ECG。
For a sudden onset of chest pain radiating to the left arm, suggestive of acute coronary syndrome (ACS), the priority sequence according to NCLEX/AHA 2024 guidelines is: obtain a 12-lead ECG (A) to determine whether it is a STEMI and assess the rhythm, then evaluate vital signs and oxygen saturation, then administer aspirin, sublingual nitroglycerin, and so on. Although the semi-Fowler position (D) reduces cardiac workload and is supportive care, it cannot replace immediate diagnostic action; positional adjustment should occur concurrently with diagnosis and assessment, but the 'priority action' is the ECG.
美國護理師常需更主動依 Protocol 啟動 Chest Pain Protocol，包含給氧與初步藥物處置。