— 藥理與非經腸給藥 · HARD · SATA —
下列哪些評估結果顯示病人對嗎啡 PCA 幫浦產生不良反應？（選所有適合的）
Which assessment findings indicate that a client is experiencing an adverse reaction to a morphine patient-controlled analgesia (PCA) pump? (Select all that apply.)
- ARespiratory rate of 8 breaths/min✓ 正解呼吸頻率為每分鐘 8 次
- BPresence of itching on the skin✓ 正解皮膚出現搔癢
- CReports of urinary retention✓ 正解主訴尿滯留
- DIncreased appetite食慾增加
- EDifficulty with arousal upon stimulation✓ 正解受到刺激時難以喚醒
— Explanation · 中文詳解 —
嗎啡為阿片類藥物，常見副作用包括呼吸抑制（呼吸速率下降）、皮膚搔癢（組織胺釋放）、尿滯留（括約肌張力增加）及鎮靜（難以喚醒）。增加食慾並非嗎啡副作用。護理師需監測鎮靜分數（Sedation Scale）以預防呼吸衰竭。
Morphine is an opioid, and common adverse effects include respiratory depression (decreased respiratory rate), pruritus (from histamine release), urinary retention (from increased sphincter tone), and sedation (with difficulty arousing). Increased appetite is not a morphine adverse effect. The nurse must monitor the sedation scale to prevent respiratory failure.
✦ 台美臨床差異
PCA 使用在美國多由麻醉科專科小組巡視；台灣則多由外科病房護理師進行常規監測，兩者對 PCA 設定權限與監測指標具一致性。