— 基本照護與舒適 · HARD · MCQ —
護理師為一位需進行中度鎮靜的病人進行準備，哪項安全措施為最高優先？
A nurse is preparing a client for a procedure requiring moderate sedation. Which safety action is the highest priority?
- AConfirm an IV line is patent and infusing確認靜脈通路暢通且正在輸注
- BConfirm the client has been NPO for the required time確認病人已禁食所需時間
- CEnsure emergency resuscitation equipment is available✓ 正解確保急救復甦設備可用
- DVerify the informed consent is signed驗證知情同意書已簽署
— Explanation · 中文詳解 —
中度鎮靜可能進展為過度鎮靜，導致呼吸抑制或氣道阻塞。因此，最高優先級是確保緊急復甦設備（如甦醒球、抽吸設備、急救車）隨時可用，以應對突發的呼吸停止或心律不整。NPO 和同意書雖重要，但屬於流程規範，並非保護氣道通暢的緊急生存措施。
Moderate sedation may progress to oversedation, leading to respiratory depression or airway obstruction. Therefore, the highest priority is to ensure that emergency resuscitation equipment (such as a bag-valve mask, suction device, and code cart) is readily available to respond to sudden respiratory arrest or dysrhythmias. NPO status and informed consent, although important, are part of procedural compliance and are not emergency measures for protecting the airway.
✦ 台美臨床差異
美國鎮靜護理執照規範嚴格，台灣常見由醫師操作，護理師監測生命徵象。