— 降低風險 · HARD · MCQ —
護理師評估一位因高血壓而靜脈注射硫酸鎂的病人，哪項發現需要立即介入？
A nurse is performing an assessment on a client with a history of hypertension who is receiving an IV infusion of magnesium sulfate. Which assessment finding requires immediate intervention?
- ARespiratory rate of 16 breaths/min呼吸頻率 16 次/分
- BAbsent patellar deep tendon reflexes✓ 正解膝腱反射消失
- CBlood pressure of 140/90 mmHg血壓 140/90 mmHg
- DUrine output of 40 mL/hr尿量 40 mL/hr
— Explanation · 中文詳解 —
硫酸鎂毒性的早期指標是深部肌腱反射（DTR）消失。肌腱反射消失預示著呼吸肌麻痺風險，需立即停止輸注並備妥葡萄糖酸鈣（Calcium gluconate）解毒。A 選項為正常呼吸頻率；C 選項為高血壓控制的臨床表現之一；D 選項顯示腎功能正常，足以排除藥物過度累積導致的毒性。
Absent deep tendon reflexes are the earliest sign of magnesium sulfate toxicity and require immediate intervention. This finding precedes respiratory depression, making it a critical indicator for stopping the infusion and administering calcium gluconate. Normal respiratory rates and adequate urine output suggest the client is currently stable.
✦ 台美臨床差異
美國護理師在產科或內科病房操作硫酸鎂 Protocol 相當成熟；台灣對於產科子癲前症使用硫酸鎂已有標準化監測規範，但給藥執行層級仍依賴醫師醫囑。