護理師照護心肌梗塞病人。監視器顯示心室搏動過速 (VT)，速率 170 次/分。病人清醒但主訴頭暈。護理師的首要行動為何？
A nurse is caring for a client with an acute myocardial infarction. The client's monitor shows ventricular tachycardia at a rate of 170/min. The client is awake but reports feeling dizzy. What is the nurse's first action?
- ACheck for a pulse✓ 正解檢查脈搏
- BPerform immediate defibrillation at 200 Joules立即以 200 焦耳進行電擊去顫
- CInitiate cardiopulmonary resuscitation (CPR)開始心肺復甦術 (CPR)
- DAdminister an IV bolus of lidocaine給予利多卡因靜脈推注
本題情境描述了一位心肌梗塞（acute myocardial infarction）病人出現心室搏動過速（Ventricular Tachycardia, VT），且心率高達 170 次/分，病人雖然清醒但主訴頭暈。這是一個典型的「有脈搏的 VT」（VT with a pulse）或稱「穩定型 VT」（stable VT）情境，但因頭暈症狀顯示血流動力學可能不穩定，需要迅速評估並介入。 在任何心律不整的急救情境中，護理師的首要行動是評估病人的血流動力學狀態。對於 VT，最關鍵的區分點是病人是否有脈搏。如果病人沒有脈搏，則應立即啟動心肺復甦（CPR）並進行去顫（defibrillation）。如果病人有脈搏，則需進一步評估其血流動力學是否穩定。此病人雖清醒但頭暈，提示血流動力學可能受損，但「檢查脈搏」是第一步，因為它直接決定了後續的處置方向，是安全且高效的臨床思路。
This client has an acute MI with ventricular tachycardia (VT) at 170/min and is awake but dizzy, suggesting hemodynamic compromise. In any dysrhythmia emergency, the nurse first assesses the patient's hemodynamic status; the most critical distinction for VT is presence or absence of a pulse. If no pulse, CPR and defibrillation are initiated. If a pulse is present, the nurse evaluates hemodynamic stability and decides between synchronized cardioversion and pharmacologic therapy. Therefore, the first action is to CHECK FOR A PULSE, which directs every subsequent step.
美國 ACLS 流程極度強調「Treat the patient, not the monitor」；台灣急救教育亦遵循相同原則。