— 照護管理 · MEDIUM · MCQ —
護理師進入病房發現病人無反應、無呼吸、無脈搏，優先採取行動為何？
A nurse enters a room and finds a client unresponsive, not breathing, and without a pulse. What is the priority action?
- ABegin rescue breathing開始急救呼吸
- BCheck the client's chart for DNR status檢查病人的病歷以確認是否有不施行心肺復甦術（DNR）狀態
- CCall for help and activate the code team✓ 正解尋求協助並啟動急救小組
- DInitiate chest compressions開始胸部按壓
— Explanation · 中文詳解 —
當發現病人無反應、無呼吸、無脈搏時，這屬於心肺停止（Cardiac arrest）的緊急狀況。根據 ACLS/BLS 指引，護理師應立即啟動緊急反應系統（呼叫團隊），並同時開始高品質的胸部按壓（Chest compressions）。胸部按壓是維持重要器官（特別是腦部）血液灌流的關鍵。除非有合法的 DNR 文件，否則應立即介入急救。
Upon finding a client unresponsive, apneic, and pulseless, the nurse must immediately activate the emergency response system to initiate the Basic Life Support (BLS) algorithm. This ensures rapid arrival of the code team and necessary equipment while high-quality chest compressions are started to maintain perfusion to vital organs.