病人正透過 PCA 幫浦接受嗎啡治療，護理師評估發現呼吸頻率為每分鐘 8 次，優先護理措施為何？
A client is receiving morphine sulfate via PCA pump. The nurse assesses the client and finds a respiratory rate of 8 breaths/min. What is the priority nursing action?
- ANotify the healthcare provider通知醫療提供者
- BStop the PCA pump✓ 正解停止 PCA 幫浦
- CAdminister naloxone施用納洛酮
- DAdminister oxygen via face mask透過面罩給氧
嗎啡為鴉片類藥物，主要副作用為呼吸抑制。正常成人呼吸頻率為 12-20 次/分，當下降至 8 次/分時，顯示病人出現嚴重的鴉片類藥物過量或中毒反應。根據 ABC（呼吸、呼吸道、循環）優先原則，護理師的首要任務是移除藥物來源以防止進一步的呼吸抑制，因此停止 PCA 幫浦是緊急的第一步。隨後才進行評估與給予輔助治療（如氧氣、Naloxone）。
Morphine is an opioid whose principal side effect is respiratory depression. The normal respiratory rate in an adult is 12–20 breaths per minute; when it falls to 8 breaths per minute, the patient is exhibiting severe opioid overdose or toxicity. According to the ABC (Airway, Breathing, Circulation) priority principle, the nurse's first task is to remove the source of the drug to prevent further respiratory depression, so stopping the PCA pump is the urgent first step. Assessment and supportive therapy (such as oxygen and naloxone) are then provided.
在美國臨床，PCA 幫浦的使用與監測有嚴格的護理規範（如 capnography 監測）。若出現呼吸抑制，護理師依據 Standing Order 停止幫浦並給予 Naloxone 是常見的職責範圍，與台灣臨床依賴醫師直接下處方有時會有執行時效上的差異。