— 照護管理 · HARD · MCQ —
一位持有 DNR 的病人發生心跳停止，護理師的首要行動為何？
A nurse is caring for a client with a DNR (Do Not Resuscitate) order. The client goes into cardiac arrest. What is the nurse's priority action?
- AContact the physician to confirm the DNR order聯絡醫師以確認 DNR 指示
- BBegin chest compressions immediately立即開始胸外按壓
- CCall a code blue呼叫緊急救援代碼（code blue）
- DAssess the client for a pulse✓ 正解評估病人是否有脈搏
— Explanation · 中文詳解 —
DNR 僅代表「不執行心肺復甦術」，並不代表終止所有的照護。在病人發生緊急狀況時，護理師必須先評估病人的生命徵象（如心跳是否存在），以確認其是否真的進入心跳停止狀態。若確認心跳停止，則遵循 DNR 指示不再進行 CPR，轉而提供舒適護理。
A DNR order means only 'do not perform cardiopulmonary resuscitation'; it does not mean termination of all care. When a client experiences an emergent change in condition, the nurse must first assess vital signs (such as the presence of a pulse) to confirm whether the client is truly in cardiac arrest. If cardiac arrest is confirmed, the DNR is honored and CPR is withheld, with the focus shifted to comfort care.
✦ 台美臨床差異
台灣 DNR 需遵循安寧緩和醫療條例，護理師需確保醫療紀錄正確性，以免在執行舒適護理時造成誤會。