— 照護管理 · MEDIUM · MCQ —
護理師照護一位使用 PCA（病人自控式止痛）的病人，最重要的一項護理措施為何？
A nurse is caring for a client who has a prescription for a PCA pump. Which of the following is the most important nursing intervention?
- ACheck the infusion site for signs of infiltration檢查輸注部位是否有滲出的跡象
- BAssess the client's respiratory rate and sedation level regularly✓ 正解定期評估病人的呼吸速率與鎮靜程度
- CMonitor the total amount of medication delivered every shift監測每班交付的藥物總量
- DInstruct the client to press the button whenever pain is felt指示病人感到疼痛時就按按鈕
— Explanation · 中文詳解 —
PCA（病人自控式止痛）給藥主要使用鴉片類藥物（Opioids），其最致命的併發症為呼吸抑制（Respiratory Depression）。在護理優先順序上，ABC原則中的呼吸道與呼吸功能永遠是第一位。透過定期的呼吸頻率與鎮靜程度評估，護理師能及早識別藥物過量造成的意識改變及呼吸抑制，並及時介入（如停藥、給予拮抗劑 Naloxone 等），這比監測輸液管路或單純的止痛效果更具生命安全性。
The most critical nursing intervention for a client using a Patient-Controlled Analgesia (PCA) pump is regular assessment of respiratory rate and sedation levels. Respiratory depression is a life-threatening complication of opioid therapy, making airway and breathing the highest priority. Early detection allows for timely intervention to prevent severe adverse outcomes.