— 降低風險 · HARD · MCQ —
護理師正在評估一位使用硫酸鎂輸注的高血壓病人，哪項評估結果最令護理師擔心？
A nurse is assessing a client with a history of hypertension who is receiving an infusion of magnesium sulfate. Which assessment finding should concern the nurse the most?
- AUrinary output of 40 mL/hr尿量 40 mL/hr
- BRespiratory rate of 10 breaths/min呼吸頻率 10 次/分
- CBlood pressure of 140/90 mmHg血壓 140/90 mmHg
- DAbsent deep tendon reflexes✓ 正解深部肌腱反射消失
— Explanation · 中文詳解 —
硫酸鎂（Magnesium sulfate）常用於治療子癲前症，其治療指數狹窄，具有神經肌肉抑制作用。中毒的早期指標是深部肌腱反射（Deep tendon reflexes, DTRs）減弱或消失。若反射消失，代表血鎂濃度已達到危險水平，必須立即停藥並備妥鈣離子拮抗劑（Calcium gluconate）作為解毒劑。
Absent deep tendon reflexes are the earliest and most concerning sign of magnesium sulfate toxicity, necessitating immediate discontinuation of the infusion. While respiratory depression is also critical, loss of reflexes typically precedes it, making it the primary indicator for urgent intervention.