病人出現敗血症徵象。護理師應優先執行哪項醫囑？
A client presents with signs of sepsis. Which order should the nurse implement first?
- AAdminister IV fluids給予靜脈輸液
- BObtain blood cultures✓ 正解採集血液培養
- CAdminister IV antibiotics給予靜脈抗生素
- DInsert a urinary catheter插入導尿管
敗血症（Sepsis）的治療關鍵在於「黃金一小時」。根據 Surviving Sepsis Campaign 指引，護理師應優先執行敗血症組合（Sepsis Bundle）。在給予抗生素之前，必須先進行血液培養，以確保細菌培養結果準確，避免抗生素干擾細菌生長，導致結果偽陰性。隨後再給予靜脈輸液復甦與廣效抗生素，以控制感染並維持器官灌流。
The key to treating sepsis lies in the "golden hour." According to the Surviving Sepsis Campaign guidelines, the nurse should prioritize implementing the sepsis bundle. Before administering antibiotics, blood cultures must be obtained to ensure accurate culture results and to avoid antibiotic interference with bacterial growth, which could produce a false-negative result. Intravenous fluid resuscitation and broad-spectrum antibiotics are then administered to control infection and maintain organ perfusion.
美國醫院對於 Sepsis Bundle 的執行有嚴格的時間窗口（例如 1 小時內），護理師在臨床上需具備高度敏銳度，一旦懷疑 sepsis 即刻啟動流程，並與跨專業團隊緊密合作。