— 藥理與非經腸給藥 · HARD · MCQ —
病人因高血壓危象接受硝普鈉（Nitroprusside）滴注。護理師的優先評估項目為何？
A client is receiving a nitroprusside infusion for a hypertensive crisis. What is the priority nursing assessment?
- AAssessment of deep tendon reflexes評估深腱反射
- BUrinary output hourly每小時監測尿液排出量
- CContinuous ECG monitoring連續心電圖監測
- DBlood pressure monitoring every 5 to 15 minutes✓ 正解每 5 至 15 分鐘監測血壓
— Explanation · 中文詳解 —
Nitroprusside 是一種極強效且快速作用的血管擴張劑，用於高血壓急症。其主要風險是導致血壓急劇下降。因此，持續且頻繁的血壓監測（每 5-15 分鐘一次）是確保病人安全、調整劑量的首要任務。此外，長期使用需注意氰化物中毒。
Nitroprusside is an extremely potent, rapidly acting vasodilator used for hypertensive emergencies. Its principal risk is causing a precipitous decrease in blood pressure. Therefore, continuous, frequent blood pressure monitoring (every 5-15 minutes) is the top priority for ensuring patient safety and titrating the dose. In addition, prolonged use requires monitoring for cyanide toxicity.
✦ 台美臨床差異
在美國，Nitroprusside 輸注通常需要侵入性動脈血壓監測（A-line）；台灣臨床亦有此要求，但若無 A-line 則需極頻繁的 NBP 監測。