— 安全與感染控制 · EASY · MCQ —
護理師進病房發現病人失去意識且無脈搏，優先採取的行動為何？
A nurse enters a room and finds the client unconscious with no pulse. What is the priority action?
- ACheck for pupil dilation檢查瞳孔是否擴大
- BCheck for respirations檢查呼吸
- CNotify the family通知家屬
- DCall for help and initiate CPR✓ 正解尋求協助並開始心肺復甦術
— Explanation · 中文詳解 —
發現病人無意識且無脈搏時，代表病人已進入心跳停止（Cardiac arrest）狀態。根據心肺復甦術（CPR）指引，護理師應立即啟動求救系統（Call for help/Code Blue）並開始進行胸外按壓。在循環受阻的情況下，每一秒的延誤都會導致腦部缺氧損傷，因此「胸外按壓」是 ABC 順序中循環（Circulation）的首要動作。
Upon finding an unconscious client with no pulse, the nurse must immediately call for help and initiate cardiopulmonary resuscitation (CPR). In cardiac arrest, early chest compressions are critical to maintain circulation and prevent brain hypoxia, making this the highest priority over checking pupils, respirations, or notifying family.