— 生理適應 · EASY · MCQ —
一名急性胰臟炎病人禁食並接受點滴治療。下列哪項護理措施對於生理穩定最為優先？
A client with acute pancreatitis is receiving IV fluids and is NPO. Which intervention is the priority for physiological stability?
- AAssess respiratory rate and lung sounds✓ 正解評估呼吸頻率和肺部聽診
- BMaintain nasogastric tube suction維持鼻胃管抽吸
- CMonitor serum lipase and amylase levels監測血清脂酶和澱粉酶水平
- DMonitor intake and output balance監測攝入量和輸出量平衡
— Explanation · 中文詳解 —
急性胰臟炎病人常合併呼吸問題，如橫膈受刺激、肋膜積液或肺塌陷。依據 ABC（Airway/Breathing/Circulation）原則，呼吸狀態（Breathing）的評估優先級極高。護理師需嚴密監測呼吸頻率與肺部聽診，及早發現呼吸窘迫。其他評估（如酵素水平、輸出入量）雖重要，但呼吸功能的穩定是病人生命安全的基礎。
Acute pancreatitis often involves respiratory complications such as diaphragmatic irritation, pleural effusion, or atelectasis. Following the ABC principle, respiratory status is high priority. The nurse must closely monitor respiratory rate and lung sounds for early detection of distress. While other assessments (enzymes, I&O) are important, respiratory stability is foundational to patient safety.