— 生理適應 · MEDIUM · MCQ —
一位急性胰臟炎病人禁食中並接受靜脈輸液，主訴上腹部劇烈疼痛放射至背部。下列何者為優先護理措施？
A client with acute pancreatitis is NPO and receiving IV fluids. The client reports severe epigastric pain radiating to the back. Which nursing intervention takes priority?
- AAuscultate for bowel sounds聽診腸鳴音
- BEncourage deep breathing exercises鼓勵深呼吸運動
- CPerform a glucose fingerstick進行指尖血糖檢測
- DAdminister prescribed analgesic✓ 正解給予處方止痛藥
— Explanation · 中文詳解 —
急性胰臟炎病人疼痛劇烈，除了影響舒適感，更會導致呼吸淺快而影響肺部擴張。優先控制疼痛可降低病人的代謝需求與壓力反應。其他選項如監測腸音或呼吸運動雖重要，但在急性疼痛期，解除痛楚是維持生理穩定與協助病人配合後續醫療處置的基礎。
Severe pain in acute pancreatitis can lead to shallow breathing and impaired lung expansion, increasing the risk of respiratory complications. Administering prescribed analgesics is the priority intervention because effective pain control reduces metabolic stress and facilitates better respiratory mechanics and patient cooperation.
✦ 台美臨床差異
美國護理師依醫囑給藥權限靈活；台灣急性疼痛控制多需醫師開立 PRN 或調整劑量，護理師需確認醫囑並評估疼痛指數。