護理師正給予不穩定型心絞痛病人靜脈注射硝酸甘油（nitroglycerin）。病人的血壓從 140/90 mmHg 下降至 90/60 mmHg。護理師應首先採取哪個措施？
A nurse is administering an IV infusion of nitroglycerin to a client with unstable angina. The client's blood pressure drops from 140/90 mmHg to 90/60 mmHg. The nurse should take which action first?
- AAdminister a dose of morphine.給予嗎啡劑量
- BIncrease the rate of the nitroglycerin infusion.增加硝酸甘油輸注速率
- CDecrease the rate or stop the nitroglycerin infusion.✓ 正解降低或停止硝酸甘油輸注
- DAdminister a bolus of normal saline.給予正常食鹽水推注
硝酸甘油（Nitroglycerin）透過產生一氧化氮（NO）導致血管平滑肌擴張，進而降低前負荷（Preload）與後負荷（Afterload）。當血壓從 140/90 降至 90/60 mmHg 時，顯示病人對藥物反應過度或出現低血壓，這會影響冠狀動脈灌流，增加心肌缺血風險。護理優先順序為停止或減量該藥物以維護血壓。
Nitroglycerin produces nitric oxide (NO), which causes vascular smooth muscle relaxation and decreases both preload and afterload. When blood pressure falls from 140/90 to 90/60 mmHg, this indicates an excessive response or hypotension, which compromises coronary artery perfusion and increases the risk of myocardial ischemia. The nursing priority is to stop the medication or reduce its dose in order to maintain blood pressure.