— 健康促進與維護 · HARD · MCQ —
一位剛接種疫苗的兒童，出現下列哪項發現需要護理師立即採取行動？
Which assessment finding in a child who has just received a vaccine requires immediate nursing action?
- AMild irritability for several hours輕微煩躁數小時
- BLow-grade fever of 37.8°C低燒 37.8°C
- CDifficulty breathing and wheezing✓ 正解呼吸困難和喘鳴
- DLocalized redness at the injection site注射部位局部紅腫
— Explanation · 中文詳解 —
接種疫苗後出現呼吸困難、喘鳴，是全身性過敏反應（Anaphylaxis）的典型徵兆，屬於危急狀況，需立即給予腎上腺素並啟動緊急救護程序。低燒、局部發紅、輕微煩躁皆為疫苗接種後的常見反應，通常給予緩解治療與監測即可。
Difficulty breathing and wheezing indicate anaphylaxis, a life-threatening allergic reaction requiring immediate intervention such as epinephrine administration. Mild irritability, low-grade fever, and localized redness are common, expected side effects that typically resolve with supportive care.
✦ 台美臨床差異
兩國醫療院所皆規定疫苗接種後須在候診區觀察 15-30 分鐘，以防範急性過敏反應。