— 生理適應 · EASY · MCQ —
病人在靜脈注射抗生素後出現過敏性休克，哪項評估結果需要立即護理處置？
A client is experiencing an anaphylactic reaction after receiving IV antibiotics. Which assessment finding requires immediate nursing intervention?
- AMild anxiety輕微焦慮
- BWheezing on auscultation✓ 正解聽診聞及哮鳴音
- CFlushing of the skin皮膚潮紅
- DLocalized urticaria局部蕁麻疹
— Explanation · 中文詳解 —
過敏性休克最致命的生理變化為呼吸道阻塞。哮鳴音提示支氣管痙攣與喉頭水腫，若不立即處理會導致呼吸衰竭。皮膚紅腫或焦慮雖也是過敏反應的指標，但呼吸道通暢性（Airway）是 ABC 原則中最優先的急救目標。
The most lethal physiologic change in anaphylactic shock is airway obstruction. Wheezing suggests bronchospasm and laryngeal edema and, if not addressed immediately, can progress to respiratory failure. Although skin flushing and anxiety are also indicators of an allergic reaction, airway patency (Airway) is the highest priority in the ABCs of emergency care.
✦ 台美臨床差異
美方護理師在急救流程中可依據緊急給藥協議（Standing order）直接給予腎上腺素；台灣多數情況仍需醫師到場後給藥。