護理師正準備給予鴉片類鎮痛劑給一位經歷嚴重疼痛的病人。病人的呼吸速率為每分鐘 10 次。首要的護理措施為何？
A nurse is preparing to administer an opioid analgesic to a client experiencing severe pain. The client's respiratory rate is 10 breaths/min. What is the priority nursing action?
- AHold the medication and notify the physician.暫停給藥並通知醫師。
- BAdminister the opioid analgesic as prescribed.按醫囑給予鴉片類鎮痛劑。
- CAdminister half the prescribed dose and re-assess.給予半劑量並重新評估。
- DAdminister the opioid analgesic and monitor respirations closely.✓ 正解給予鴉片類鎮痛劑並密切監測呼吸。
鴉片類藥物（opioids）主要副作用為呼吸抑制。當呼吸速率降至 10 次/分時，護理師需評估病人是否出現其他呼吸抑制徵兆（如意識模糊、血氧飽和度下降）。若病人仍有嚴重疼痛，給藥前需權衡疼痛控制與呼吸安全。在 NCLEX 題目中，若呼吸接近但未達極度危險（<8-10 次/分），優先做法通常是給藥同時加強監測。
The principal adverse effect of opioids is respiratory depression. When the respiratory rate falls to 10 breaths/min, the nurse must assess the client for other signs of respiratory depression (such as altered level of consciousness or decreased oxygen saturation). If the client still has severe pain, the nurse must weigh pain control against respiratory safety before administration. In NCLEX questions, when respirations are close to but not yet at the critically dangerous level (<8-10 breaths/min), the preferred approach is usually to administer the medication while strengthening monitoring.