一位病人起身時血壓突然降至 85/50 mmHg。護理師應優先採取哪項措施？
A client experiences a sudden drop in blood pressure to 85/50 mmHg upon standing. Which nursing action is most appropriate?
- AAdminister 500 mL of normal saline IV bolus靜脈快速注射500 mL生理鹽水
- BObtain an EKG to check for arrhythmias進行心電圖檢查以確認是否有心律不整
- CAdvise the client to sit back down immediately✓ 正解建議病人立即坐回原位
- DCall the physician for vasopressor orders聯絡醫師以取得升壓劑醫囑
此題核心為評估姿態性低血壓（Orthostatic Hypotension）的緊急處置。當病人出現姿勢改變後的低血壓，最立即的風險是腦部灌流不足導致暈厥（Syncope）與跌倒（Fall）。護理師應採取「安全性優先（Safety First）」原則，立即中斷導致低血壓的動作，讓病人回到穩定姿勢以增加回心血量，隨後再進行評估與通報，這符合 NCLEX 對於預防跌倒與病患安全的最高準則。
The core of this item is the emergency management of orthostatic hypotension. When a patient becomes hypotensive after a change in position, the most immediate risk is inadequate cerebral perfusion leading to syncope and falls. The nurse should apply the safety-first principle and immediately interrupt the action that caused the hypotension, returning the patient to a stable position to increase venous return, and only then proceed with assessment and notification. This aligns with NCLEX's highest standard for fall prevention and patient safety.