— 生理適應 · MEDIUM · MCQ —
護理師照護一名低血容積休克的病人，下列哪項護理介入優先級最高？
A nurse is caring for a client with hypovolemic shock. Which intervention has the highest priority?
- AAdministering oxygen via face mask透過面罩給予氧氣
- BElevating the head of the bed抬高床頭
- CStarting two large-bore IV lines✓ 正解建立兩條大管徑靜脈通路
- DAssessing the client's psychological state評估客戶的心理狀態
— Explanation · 中文詳解 —
低血容積休克的主要病理是循環量不足，首要目標是補充體液以維持灌流。建立兩條大號管徑（large-bore）靜脈輸液路徑可進行快速輸液復甦，優先維持循環。雖然給氧也很重要，但輸液復甦才是針對此類型休克根本病理的急救手段。
The main pathophysiology of hypovolemic shock is an insufficient circulating volume, and the primary goal is fluid replacement to maintain perfusion. Establishing two large-bore IV lines enables rapid fluid resuscitation and prioritizes maintaining circulation. Although oxygen administration is also important, fluid resuscitation directly addresses the underlying problem of this type of shock and is the priority emergency intervention.
✦ 台美臨床差異
美國護理師在 ACLS 證照訓練中非常強調急救路徑的建立；台灣護理師亦具備此能力，但藥物給予常需等待醫師指示。