— 藥理與非經腸給藥 · HARD · MCQ —
護理師照護一位接受硫酸鎂點滴輸注的病人。下列哪項發現需優先回報醫師？
A nurse is caring for a client receiving an infusion of magnesium sulfate. Which finding is the highest priority to report to the provider?
- AClient reports feeling warm案主表示感到溫暖
- BPatellar reflex is 1+膝腱反射為 1+
- CBlood pressure of 110/70 mmHg血壓 110/70 mmHg
- DRespiratory rate of 10 breaths/min✓ 正解呼吸頻率 10 次/分
— Explanation · 中文詳解 —
硫酸鎂具有抑制呼吸中樞的副作用。呼吸速率低於 12 次/分是呼吸抑制的早期訊號，為生命危險徵兆，必須優先處理。D 的反射減弱（1+）雖然也是鎂中毒指標，但 ABC 中的呼吸（Breathing）永遠優於反射檢查（Disability）。
Magnesium sulfate has the side effect of depressing the respiratory center. A respiratory rate below 12 breaths/min is an early sign of respiratory depression, a life-threatening cue that must be prioritized. The diminished reflex (1+) in option B is also a sign of magnesium toxicity, but within the ABCs, breathing always takes precedence over the reflex examination (Disability).
✦ 台美臨床差異
美台臨床對於硫酸鎂中毒的監測（鈣離子作為拮抗劑備用）標準一致，但美國護理師對毒性監測的獨立決策權較大。