— 藥理與非經腸給藥 · EASY · MCQ —
護理師對於接受靜脈注射嗎啡的病人,應優先評估什麼?
Which assessment is priority for a client receiving IV morphine?
- ABlood pressure血壓
- BRespiratory rate✓ 正解呼吸頻率
- CBowel sounds腸鳴音
- DLevel of pain疼痛程度
— Explanation · 中文詳解 —
嗎啡(Morphine)屬於鴉片類止痛藥(Opioids),其主要藥理機轉為抑制中樞神經系統,包括腦幹的呼吸中樞。在 NCLEX 考試中,處理病人照護問題時,必須運用「ABC」(Airway, Breathing, Circulation)護理優先原則。呼吸抑制是嗎啡最致命的副作用,因此在給藥前後,護理師必須優先評估呼吸頻率、深度與血氧飽和度,以確保病人的呼吸功能穩定。
Morphine is an opioid that depresses the brainstem respiratory center. Following the ABC (airway, breathing, circulation) framework, respiratory rate and depth are the priority assessment. If respirations are below 12/min, the nurse should hold further doses and consider naloxone.