— 生理適應 · MEDIUM · MCQ —
病人使用抗生素後反映嚴重的搔癢感。護理師的優先護理處置為何？
A client reports severe itching after receiving an antibiotic. What is the priority nursing intervention?
- AAdminister an antihistamine給予抗組織胺
- BNotify the provider通知醫師
- CAssess respiratory status評估呼吸狀態
- DStop the infusion✓ 正解停止輸注
— Explanation · 中文詳解 —
病人使用藥物後出現搔癢，極可能是過敏反應（Hypersensitivity reaction）的早期徵兆。護理師的第一優先行動是「停止輸入過敏原」，即刻關閉點滴輸注。這是防止過敏反應演變為致命的過敏性休克（Anaphylaxis）的最關鍵動作。隨後才進行呼吸評估、通知醫師及準備給予抗組織胺或腎上腺素等急救藥物。安全原則強調移除致病原因。
Severe itching suggests a hypersensitivity reaction, so the priority nursing intervention is to immediately stop the infusion to remove the allergen. This action prevents the progression to anaphylaxis. Subsequent steps include assessing respiratory status, notifying the provider, and administering medications like antihistamines or epinephrine.