— 藥理與非經腸給藥 · MEDIUM · MCQ —
護理師照護一位使用 PCA 輸注幫浦的病人。哪項評估是護理師的首要任務？
A nurse is caring for a client with a PCA pump. Which assessment is priority for the nurse to perform?
- ACheck the IV site for signs of infiltration檢查靜脈注射部位是否有滲漏跡象
- BCheck the amount of medication left in the syringe檢查注射器中剩餘的藥物量
- CAsk the client how they are managing their pain詢問病人如何控制其疼痛
- DAssess respiratory rate and sedation level✓ 正解評估呼吸頻率與鎮靜程度
— Explanation · 中文詳解 —
PCA 的最大安全風險是鴉片類藥物過量導致呼吸抑制（Respiratory depression）。無論疼痛控制如何，監測呼吸速率與意識程度（Sedation scale）是保障病人安全的首要評估項目。
The priority assessment for a client using a patient-controlled analgesia (PCA) pump is monitoring respiratory rate and sedation levels, as opioid-induced respiratory depression is the most life-threatening complication. While pain management and IV site integrity are important, ensuring airway and breathing safety takes precedence over other assessments.
✦ 台美臨床差異
台美皆非常重視 PCA 的給藥紀錄與監測，美國對鎮靜程度（Sedation score）的監測標準極為嚴謹，台灣亦多納入常規流程。