— 生理適應 · HARD · SATA —
病人疑似心肌梗塞，護理師應執行哪些必要措施？（選所有適合的）
A client presents with a suspected myocardial infarction. Which nursing actions are essential? (Select all that apply.)
- AAdminister oxygen to maintain SpO2✓ 正解給予氧氣以維持 SpO2
- BAdminister aspirin as per protocol✓ 正解依協議給予阿斯匹靈
- CObtain a 12-lead ECG✓ 正解取得 12 導程心電圖
- DPrepare the client for an emergency CABG準備病人接受緊急冠狀動脈繞道手術 (CABG)
- EAdminister nitroglycerin as prescribed✓ 正解依處方給予硝酸甘油
— Explanation · 中文詳解 —
心肌梗塞急救遵循 MONA 原則（Morphine, Oxygen, Nitroglycerin, Aspirin）及心電圖評估。CABG 是後期治療選項，非初步急救。護理師應先穩定生命跡象、給氧、給予阿斯匹靈及硝酸甘油以擴張冠狀動脈。
Continuous bubbling in the water-seal chamber indicates a significant air leak within the chest tube system or the pleural space. Normal function involves intermittent bubbling only during coughing or deep breathing. This finding requires immediate assessment of connections and the patient to locate the source of the leak.
✦ 台美臨床差異
美國護理師在 ED 可依據流程直接給藥；台灣多需醫師看過心電圖後才開立醫囑給予藥物。