— 安全與感染控制 · HARD · MCQ —
下列哪項評估結果需要護理師立即介入以預防病人安全事件？
Which assessment finding requires immediate nursing action to prevent a client safety incident?
- AThe client has a low potassium level of 3.2 mEq/L病人的鉀離子水平偏低，為3.2 mEq/L
- BThe client's intravenous infusion is running at 150 mL/hr instead of 100 mL/hr病人的靜脈輸液速率為150 mL/hr，而非處方的100 mL/hr
- CThe client's dressing is saturated with serosanguinous drainage病人的敷料被血清血性引流液浸透
- DThe client is experiencing sudden chest pain✓ 正解病人經歷突發性胸痛
— Explanation · 中文詳解 —
依照優先順序準則（ABC 原則），循環問題（胸痛）通常暗示急性心肌梗塞，具有高度威脅生命的風險，因此必須優先處理。A（鉀離子低）重要但通常是緩慢矯正；B（點滴速度快）需調整但不如胸痛緊急；D（傷口渗液）需處理但病人生命徵象若穩定則屬次要。
According to priority-setting principles (the ABC framework), a circulatory problem such as chest pain typically suggests acute myocardial infarction and carries a high risk to life, so it must be addressed first. A (low potassium) is important but is usually corrected gradually; B (an IV running faster than ordered) requires adjustment but is not as urgent as chest pain; D (a saturated dressing) needs management but is secondary if the client's vital signs are stable.
✦ 台美臨床差異
兩地對於胸痛病人的處置皆遵循 ACLS 與急診分級標準，沒有差異。