— 生理適應 · HARD · MCQ —
對於出現過敏性休克（Anaphylaxis）症狀的病人，護理師應採取哪項行動？
Which action should the nurse take for a client presenting with symptoms of anaphylaxis?
- ACheck the client's vital signs every 15 minutes每 15 分鐘測量病人生命徵象
- BWait for the physician's order to administer epinephrine等待醫師指示給予腎上腺素
- CImmediately administer epinephrine✓ 正解立即給予腎上腺素
- DAdminister an antihistamine給予抗組織胺
— Explanation · 中文詳解 —
過敏性休克（Anaphylaxis）是一種急性、全身性且具致命性的過敏反應。腎上腺素（Epinephrine）是唯一能透過 alpha 與 beta 受體作用，迅速緩解支氣管痙攣並提升血管收縮以逆轉休克的藥物。在臨床情境中，護理師應具備緊急給藥的權限或根據已建立的急救流程立即執行，等待醫囑會嚴重延誤黃金救援時間。
Anaphylaxis is a life-threatening systemic allergic reaction requiring immediate intervention. Epinephrine is the first-line treatment because it rapidly reverses bronchospasm and vasodilation via alpha and beta receptor stimulation. Nurses should administer it immediately based on standing orders or protocols rather than waiting for a physician's specific directive.
✦ 台美臨床差異
美國醫院多有針對過敏性休克的 Standardized Order Set，護理師在確認臨床徵象後可直接啟動給藥，台灣法律環境下，護理師若未取得醫師口頭醫囑或急救醫囑，通常不敢先行給藥。