— 藥理與非經腸給藥 · HARD · MCQ —
一位重度子癇前症病人正在接受硫酸鎂靜脈點滴，哪一項評估結果需要護理師立即介入？
A client is receiving an IV infusion of magnesium sulfate for severe preeclampsia. Which assessment finding requires immediate nursing intervention?
- AUrinary output is 40 mL per hour每小時尿液排出量為 40 mL
- BRespiratory rate is 10 breaths per minute✓ 正解呼吸頻率為每分鐘 10 次
- CSerum magnesium level is 7 mg/dL血清鎂濃度為 7 mg/dL
- DDeep tendon reflexes are 1+深層肌腱反射為 1+
— Explanation · 中文詳解 —
硫酸鎂（Magnesium sulfate）常被用於預防子癇前症（Preeclampsia）病人的癲癇發作。由於其主要經腎臟排泄，且治療窗狹窄，極易發生中毒。護理師必須密切監測中毒三徵象：深部肌腱反射（DTR）減弱或消失、呼吸速率過慢（<12次/分）、尿量減少（<30mL/hr）。若呼吸速率低於 12 次/分，表示中樞神經受到嚴重抑制，必須立即停止輸注並給予鈣劑（Calcium gluconate）解毒。
Respiratory depression is a critical sign of magnesium sulfate toxicity, which can be life-threatening. A respiratory rate below 12 breaths per minute indicates central nervous system suppression and requires immediate cessation of the infusion and administration of calcium gluconate.