— 生理適應 · HARD · SATA —
病人在靜脈注射抗生素後出現過敏性休克徵兆，護理師應採取哪些措施？（選所有適合的）
A client develops signs of anaphylaxis following the administration of intravenous antibiotics. Which actions should the nurse take? (Select all that apply.)
- AStop the antibiotic infusion immediately✓ 正解立即停止抗生素靜脈注射
- BAdminister epinephrine as prescribed✓ 正解依醫囑給予腎上腺素
- CPlace the client in a high-Fowler's position將病人置於高福勒氏體位
- DMaintain patent airway and provide oxygen✓ 正解維持呼吸道暢通並提供氧氣
- EIncrease the rate of IV maintenance fluids✓ 正解增加靜脈維持輸液的速率
— Explanation · 中文詳解 —
過敏性休克處理原則為立即阻斷過敏原、給予急救藥物與支持生命徵象。停止輸液是第一步；腎上腺素是治療過敏性休克的首選藥物；氣管暢通與供氧可改善呼吸窘迫；快速補充液體可緩解因血管擴張導致的低血壓。病人應平躺或微抬下肢以利回心血量，而非高坐臥位。
The priority actions include stopping the allergen, administering epinephrine to reverse bronchoconstriction and vasodilation, and maintaining a patent airway with oxygen. Increasing IV fluids helps counteract distributive shock, while placing the client in a supine position with legs elevated supports venous return better than sitting upright.
✦ 台美臨床差異
美台臨床對於過敏性休克處置邏輯一致，但美國護理師依據急救流程自主給予腎上腺素頻率較高。