— 生理適應 · MEDIUM · MCQ —
一位創傷病患出現心搏過速與低血壓，護理師懷疑內出血。首要措施為何？
A patient with a traumatic injury is experiencing tachycardia and hypotension. The nurse suspects hemorrhage. What is the priority intervention?
- AElevate the legs抬高下肢
- BStart high-flow oxygen開始給予高流量氧氣
- CPerform a neurological assessment進行神經系統評估
- DApply pressure to external bleeding sites✓ 正解對外部出血部位施加壓力
— Explanation · 中文詳解 —
面對創傷導致的低血壓與心搏過速，護理師的首要任務是應用 ABC（Airway, Breathing, Circulation）原則中的循環（Circulation）支持。內出血或外出血造成的低血容量性休克（Hypovolemic shock）需優先處理出血源，以防止血容積進一步喪失，這是維持器官灌流的最關鍵步驟。直接壓迫外部出血點能最快速、有效地物理性阻斷血液流失，是護理師在第一時間即可執行的救命介入。
In a trauma client presenting with signs of hypovolemic shock, the priority intervention is to control external bleeding to stabilize circulation and prevent further blood loss. While oxygen and leg elevation have roles, directly stopping the source of hemorrhage is the most critical immediate action to maintain organ perfusion and hemodynamic stability.