— 生理適應 · MEDIUM · MCQ —
個案呈現低血容性休克徵象。護理師應預期首要執行的處置為何？
A client presents with signs of hypovolemic shock. Which of the following should the nurse anticipate first?
- AObtain serial vital signs測量連續生命徵象
- BAdminister vasopressors給予血管收縮劑
- CInsert a Foley catheter插入導尿管
- DInitiate large-bore IV access✓ 正解建立大口徑靜脈通路
— Explanation · 中文詳解 —
低血容休克核心問題為循環血量不足，建立大口徑靜脈通路（Large-bore IV）是給予大量輸液治療（Fluid Resuscitation）的前提。Vasopressors 在回補血量後若血壓仍低才考慮；導尿管用於監測尿量，非最首要；生命徵象雖重要，但治療步驟優先於監測。
Initiating large-bore intravenous access is the priority to allow for rapid fluid resuscitation, which addresses the core issue of hypovolemia. Vasopressors are considered only after volume replacement if blood pressure remains unstable, making IV access the essential first step.
✦ 台美臨床差異
美國急診護理師常依據 Sepsis 或 Shock Protocol 自行執行建立 IV；台灣臨床通常需要醫師簽署醫囑才能進行大規模補液。