— 照護管理 · HARD · SATA —
病人在急診室發生心跳停止，搶救過程中哪些護理措施最合適？（選所有適合的）
A client in the emergency department is experiencing a cardiac arrest. Which actions by the nurse are most appropriate during the resuscitation effort? (Select all that apply.)
- AEnsuring a backboard is placed under the client✓ 正解確保在個案下方放置背板
- BAssigning one team member to document all interventions✓ 正解指派一名隊員負責記錄所有介入措施
- CStopping compressions to check for a pulse every 30 seconds每 30 秒停止按壓以檢查脈搏
- DRecording the exact time of medication administration✓ 正解記錄給藥的精確時間
- ELimiting interruptions in chest compressions to less than 10 seconds✓ 正解將胸外按壓的中斷時間限制在 10 秒以內
— Explanation · 中文詳解 —
心肺復甦（CPR）需高效率進行。放置背板以確保按壓深度；指派記錄者確保介入時間精確，有助於後續急救策略。按壓中斷時間不可超過 10 秒。選項 C 錯誤：每 30 秒檢查脈搏太頻繁，會嚴重影響循環灌流，應維持 2 分鐘循環。
Effective CPR requires a firm surface, such as a backboard, to ensure adequate chest compression depth. Team members must limit interruptions in compressions to less than 10 seconds to maintain perfusion, and one person should document interventions with exact times to facilitate communication and track time-sensitive medications.
✦ 台美臨床差異
美台皆遵循 ACLS/BLS 指引，但在急救團隊角色分配上，美國傾向任務導向明確，台灣則強調團隊領導人（Team Leader）的統籌。