一位 45 歲高血壓病史病患主訴劇烈頭痛、視力模糊及噁心，血壓 210/130 mmHg。護理師應優先執行哪項措施？
A 45-year-old client with a history of hypertension reports a sudden, severe headache, blurred vision, and nausea. The blood pressure is 210/130 mmHg. Which nursing action is the highest priority?
- AAdminister an oral antihypertensive medication給予口服降壓藥物
- BPlace the client in a semi-Fowler's position將病人置於半坐臥位（semi-Fowler's position）
- CObtain a neurological assessment進行神經學評估
- DEstablish intravenous access for emergency medication✓ 正解建立靜脈通路以給予急救藥物
此個案呈現高血壓急症（Hypertensive Emergency），需立即進行藥物治療以防器官受損。護理師應首要建立靜脈路徑（IV access），以便後續給予強效降壓藥物（如 Nitroprusside 或 Labetalol）。A為重要評估，但優先級次於建立治療路徑；B不可給口服藥，因為需精確控制降壓速度；C為輔助體位，非挽救生命的第一步。
This client is experiencing a hypertensive emergency, characterized by severely elevated blood pressure with signs of end-organ damage, requiring immediate intervention to prevent further injury. Establishing intravenous access is the highest priority to facilitate the rapid administration of titratable antihypertensive medications. Oral medications are inappropriate due to unpredictable absorption, and while assessment is important, securing the route for life-saving treatment takes precedence.
美方在急診或 ICU 對高血壓急症多由護理師根據協議建立通路，台灣則多在確認醫囑後執行，但在緊急狀況下均以保護循環為主。