— 藥理與非經腸給藥 · MEDIUM · SATA —
在接受鴉片類止痛藥的病人中，出現哪些跡象需要護理師立即介入？（選所有適合的）
Which of the following findings in a client receiving an opioid analgesic indicates the need for immediate nursing intervention? (Select all that apply.)
- ARespiratory rate of 8 breaths/min✓ 正解呼吸速率為每分鐘 8 次
- BSedation scale level 4✓ 正解鎮靜量表等級 4
- CConstipation便秘
- DPinpoint pupils針尖樣瞳孔
- EDifficulty arousing the client✓ 正解難以喚醒病人
— Explanation · 中文詳解 —
鴉片類藥物主要副作用為呼吸抑制與中樞神經抑制。呼吸速率 <10 次/分、鎮靜程度高、難以喚醒均顯示病人有生命危險，必須優先處理（如刺激、給予 Naloxone）。便秘屬常見副作用但非緊急生命徵象，針狀瞳孔為藥物作用跡象但不一定需要干預。
Opioid analgesics can cause severe respiratory depression and central nervous system sedation, which are medical emergencies requiring immediate intervention. A respiratory rate of 8 breaths/min, a high sedation scale level, and difficulty arousing the client all indicate potential respiratory failure or overdose. While constipation and pinpoint pupils are common side effects, they do not pose an immediate threat to life.
✦ 台美臨床差異
台美護理師皆需熟練使用 Narcan 以應對鴉片類藥物過量，且監測標準相同。