— 降低風險 · MEDIUM · SATA —
一位病人正經歷急性氣喘發作，下列哪些處置應列為優先？（選所有適合的）
A nurse is caring for a client experiencing an acute asthma attack. Which interventions are appropriate to prioritize? (Select all that apply.)
- AAdminister high-flow oxygen via mask經面罩給予高流量氧氣
- BAdminister short-acting beta-agonist (SABA)✓ 正解給予短效型乙型交感神經刺激劑 (SABA)
- CPlace the client in a high-Fowler's position✓ 正解將病人置於高福勒氏體位
- DEncourage the client to talk to assess the ability to breathe鼓勵病人說話以評估其呼吸能力
- EAdminister systemic corticosteroids as prescribed✓ 正解依醫囑給予全身性皮質類固醇
— Explanation · 中文詳解 —
氣喘發作處置重點在於擴張氣管（SABA）與減輕發炎（類固醇）。採取高坐位（High-Fowler's）有助於肺部擴張。選項 A：氣喘病人通常只需低流量氧氣以維持 SpO2，除非嚴重缺氧，否則非首選。選項 D：應盡量減少病人說話，以保存體力並降低耗氧量。
Continuous bubbling in the water-seal chamber indicates an air leak in the system or persistent leakage from the pleural space, which compromises the creation of negative pressure needed for lung re-expansion. This finding requires immediate assessment of tubing connections and client status to prevent complications like tension pneumothorax.
✦ 台美臨床差異
美台皆遵循 GINA 指引，但台灣醫囑中類固醇給藥時機常需醫師評估，護理師衛教則著重吸入器使用。