護理師正在照護一名患有急性失代償性心臟衰竭並接受硝酸甘油（Nitroglycerin）持續輸注的病人。護理師發現病人的血壓從 138/84 mmHg 下降至 92/58 mmHg。護理師應首先採取哪項行動？
A nurse is caring for a client with acute decompensated heart failure who is receiving a continuous infusion of nitroglycerin. The nurse notes the client's blood pressure has decreased from 138/84 mmHg to 92/58 mmHg. Which action should the nurse take first?
- APerform a 12-lead electrocardiogram (ECG)進行 12 導程心電圖（ECG）。
- BIncrease the rate of the primary IV maintenance fluid增加主要靜脈維持輸液的速率。
- CDecrease the infusion rate of nitroglycerin✓ 正解降低硝酸甘油的輸注速率。
- DAdminister a bolus of normal saline給予正常食鹽水推注。
此題的核心概念是藥物副作用管理與病人安全。硝酸甘油是一種強效的血管擴張劑，主要透過降低前負荷和後負荷來減輕心臟負擔，但其最常見且危險的副作用就是低血壓。當病人血壓明顯下降（收縮壓低於 90-100 mmHg）時，護理師的首要任務是減少或停止導致低血壓的藥物。這符合『移除致病因素』的優先原則。調慢點滴速度（C）是目前最直接、最能立即阻止血壓繼續下滑的處置。雖然增加基礎輸液（B）或給予輸液挑戰（D）可以提升血壓，但在急性心臟衰竭病人身上，過多的水分可能誘發肺水腫，因此並非首選。12導程心電圖（A）雖然重要，但在生命徵象不穩定的當下，應先穩定循環狀態，再進行診斷性檢查。臨床決策路徑應始於穩定生命徵象（ABC），隨後才是進一步評估。
Core concept: drug adverse effect management and patient safety. Nitroglycerin is a potent vasodilator that reduces preload and afterload to relieve cardiac workload; its most common dangerous adverse effect is hypotension. When the BP drops significantly (systolic below 90-100 mmHg), the nurse's first priority is to decrease or stop the offending drug. This follows the 'remove the cause' principle. Slowing the infusion rate (C) is the most direct and immediate way to halt further BP decline. Increasing maintenance fluids (B) or giving a fluid bolus (D) can raise BP, but in acute decompensated heart failure these can precipitate pulmonary edema and are not first-line. A 12-lead ECG (A), while useful, should follow circulatory stabilization. The clinical pathway is to stabilize ABCs before further diagnostics.
在美國，ICU 或心臟專科護理師通常有基於 protocol 的自主權，可根據血壓目標值直接微調（titrate）硝酸甘油劑量；在台灣，雖有類似 protocol，但多數仍需在調整後立即口頭或電子通報醫師核可，且對自主調整的範圍限制較嚴格。