一名 55 歲高血壓病史病患主訴突發性壓迫性胸痛並放射至左下顎，且伴隨盜汗。護理師首要介入措施為何？
A 55-year-old client with a history of hypertension reports a sudden, crushing chest pain that radiates to the left jaw. The nurse notes the client is diaphoretic. What is the priority nursing intervention?
- AObtain vital signs and pulse oximetry測量生命徵象與脈搏血氧濃度
- BApply supplemental oxygen給予補充氧氣
- CObtain a 12-lead electrocardiogram✓ 正解進行十二導程心電圖檢查
- DAdminister sublingual nitroglycerin給予舌下硝酸甘油
對於疑似 ACS 的胸痛病人，依 AHA 2020 指引，應**僅在 SpO2 < 90% 或有呼吸窘迫時**給氧；對於血氧正常者，常規給氧已不再被建議（可能增加心肌缺血程度）。優先動作是 12 導程 ECG（C），可即時辨識 STEMI、缺血性變化或心律不整，引導後續藥物（aspirin、nitroglycerin）與導管室處置。其他選項：D 硝化甘油在血壓未確認下給予可能造成低血壓；C 常規給氧已不建議；D 生命徵象與 SpO2 應同步取得，但 ECG 為最具特異性的診斷動作。
For chest pain suggestive of ACS, according to the AHA 2020 guidelines oxygen should be administered ONLY if SpO2 < 90% or there is respiratory distress; routine supplemental oxygen is no longer recommended for normoxic patients (it may worsen myocardial ischemia). The priority action is to obtain a 12-lead ECG (C), which can promptly identify STEMI, ischemic changes, or dysrhythmias and guide subsequent medications (aspirin, nitroglycerin) and catheterization-lab decisions. Regarding the other options: A, sublingual nitroglycerin given without verified blood pressure may cause hypotension; C, routine oxygen is no longer recommended; D, vital signs and SpO2 should be obtained concurrently, but the ECG is the most specific diagnostic action.