— 基本照護與舒適 · HARD · MCQ —
病人預計進行中度鎮靜（Moderate sedation）下的手術。護理師哪項觀察是必須的？
A client is scheduled for a procedure under moderate sedation. Which nursing observation is essential?
- AMonitoring pulse oximetry✓ 正解監測脈搏血氧飽和度
- BMonitoring urine output監測尿液排出量
- CChecking deep tendon reflexes檢查深腱反射
- DAssessing capillary refill評估毛細血管再充盈時間
— Explanation · 中文詳解 —
中度鎮靜病人仍維持呼吸自主，但有呼吸抑制風險，因此監測脈搏血氧（Pulse oximetry, A）以確保換氣效能是護理核心。深腱反射（C）通常用於 neurologically 評估，毛細血管充盈（D）是循環評估，尿量（B）是長期評估，皆非鎮靜監測重點。
Monitoring pulse oximetry is essential because moderate sedation carries a significant risk of respiratory depression. Ensuring adequate oxygenation and ventilation is the priority nursing intervention, whereas assessments like urine output or deep tendon reflexes are not immediately critical for sedation safety.
✦ 台美臨床差異
美國有針對鎮靜評估的嚴格指引（如麻醉護理）；台灣對中度鎮靜監測亦有類似規範。