護理師照護一位疑似對抗生素輸注有過敏反應的病人,第一項護理行動為何?
A nurse is caring for a client with a suspected allergic reaction to an antibiotic infusion. What is the first nursing action?
- AStop the antibiotic infusion✓ 正解停止抗生素輸注
- BAdminister diphenhydramine給予苯海拉明
- CNotify the provider通知醫師
- DAssess the client's vital signs評估個案的生命徵象
面對疑似抗生素輸注過敏反應,護理師的首要任務是「移除過敏原」。抗生素輸注過敏可能迅速進展為全身性過敏反應(Anaphylaxis),甚至導致呼吸道阻塞與休克。停止輸注是切斷過敏原來源最直接且有效的行動。遵循 ABC(呼吸道、呼吸、循環)原則,在移除過敏原後,護理師應評估氣道與生命徵象,隨後通知醫師並準備給予急救藥物(如腎上腺素 epinephrine)。
When a suspected allergic reaction to an antibiotic infusion occurs, the nurse's first priority is to remove the allergen. Antibiotic infusion reactions can rapidly progress to systemic anaphylaxis, even leading to airway obstruction and shock. Stopping the infusion is the most direct and effective action to eliminate the source of the allergen. Following the ABC (Airway, Breathing, Circulation) principle, after removing the allergen, the nurse should assess the airway and vital signs, then notify the provider and prepare to administer emergency medications (e.g., epinephrine).
在美國臨床環境中,護理師擁有「獨立判斷並立即停止輸液」的權限,無需等待醫師指令。這與台灣部分醫院習慣先確認或通知醫師才採取行動的文化不同,NCLEX 強調的是護理師的自主性(Autonomy)與安全第一(Safety First)。