— 生理適應 · MEDIUM · MCQ —
一名急性胰臟炎病人主訴上腹劇烈疼痛，下列哪項護理措施為最高優先？
A client with acute pancreatitis reports severe epigastric pain. Which nursing intervention is the highest priority?
- AMaintain NPO status and administer IV fluids✓ 正解維持禁食（NPO）狀態並給予靜脈輸液
- BEncourage deep breathing and coughing鼓勵深呼吸和咳嗽
- CMonitor serum amylase and lipase levels監測血清澱粉酶和脂肪酶水平
- DAdminister pain medication as ordered依醫囑給予止痛藥
— Explanation · 中文詳解 —
急性胰臟炎治療核心為禁食（NPO）以使胰臟休息，並給予靜脈輸液維持血流動力學穩定，防止脫水進展為休克。雖然緩解疼痛（D）也很重要，但若不進行 NPO 和輸液，胰臟會持續受到消化酵素刺激，導致病情惡化。
The core treatment of acute pancreatitis is NPO status to rest the pancreas, with IV fluids to maintain hemodynamic stability and prevent dehydration from progressing to shock. Although pain relief (option D) is also important, without NPO and fluid resuscitation the pancreas continues to be stimulated by digestive enzymes, causing the condition to worsen.
✦ 台美臨床差異
美方護理師在醫囑下可更靈活調整靜脈輸液速率以達到復甦效果，台灣則較常嚴格遵守醫囑給藥速率。