— 生理適應 · HARD · SATA —
病人出現敗血症跡象，護理師預期在第一小時內需執行哪些處置？（選所有適合的）
A client presents with signs of sepsis. Which interventions should the nurse anticipate initiating in the first hour? (Select all that apply.)
- AObtain blood cultures before antibiotic administration✓ 正解在給藥前採集血液培養
- BAdminister broad-spectrum intravenous antibiotics✓ 正解給予廣效型靜脈注射抗生素
- CAdminister a fluid bolus of 30 mL/kg of crystalloid✓ 正解給予30 mL/kg的結晶體液推注
- DMeasure serum lactate levels✓ 正解測量血清乳酸濃度
- EStart a long-term total parenteral nutrition開始長期總靜脈營養
— Explanation · 中文詳解 —
敗血症的「一小時急救包」（Sepsis Bundle）是提升存活率的關鍵。內容包括：測量乳酸值（評估組織缺氧）、在給予抗生素前採集血液培養（確保診斷正確）、儘速給予廣效抗生素（抑制細菌增殖），以及給予 30 mL/kg 的晶體液輸注（擴張血容量，糾正低血壓與組織灌流不足）。這些措施必須在第一小時內同步啟動。
The 'One-Hour Sepsis Bundle' is critical for improving survival rates and includes measuring serum lactate to assess tissue hypoperfusion, obtaining blood cultures before administering antibiotics to ensure accurate diagnosis, initiating broad-spectrum intravenous antibiotics promptly, and administering a 30 mL/kg crystalloid fluid bolus to restore volume and correct hypotension.