— 照護管理 · MEDIUM · MCQ —
護理師照顧一位胸痛的病人，應優先採取哪項行動？
A nurse is caring for a client experiencing chest pain. Which action should the nurse take first?
- AAssess the client's vital signs and pain level✓ 正解評估病人的生命徵象與疼痛程度
- BObtain an EKG取得心電圖
- CNotify the physician通知醫師
- DAdminister oxygen to maintain saturation給予氧氣以維持血氧飽和度
— Explanation · 中文詳解 —
胸痛（Chest pain）處理首重評估。在執行任何處置（如給氧或 EKG）前，必須先評估病人的生命跡象與疼痛性質，確認是否為心肌梗塞或其他緊急情況。這能提供後續醫囑（如給予硝酸甘油）的重要評估數據，也是確保救護安全的第一步。
Management of chest pain must begin with assessment. Before any intervention (such as administering oxygen or obtaining an EKG), the nurse must assess vital signs and the nature of the pain to determine whether myocardial infarction or another emergency is occurring. This provides essential data for subsequent orders (such as administering nitroglycerin) and is the first step in ensuring safe resuscitative care.
✦ 台美臨床差異
美台對於胸痛處理皆遵循急性冠心症標準流程（ACS Protocol），評估先行皆為共識。