— 生理適應 · HARD · MCQ —
病人出現低血容性休克徵象。護理師應優先執行哪項措施？
A client presents with signs of hypovolemic shock. Which intervention should the nurse prioritize?
- AInitiate two large-bore IV catheters✓ 正解建立兩條大口徑靜脈導管
- BObtain a baseline ECG取得基線心電圖
- CAdminister vasopressors給予血管收縮劑
- DPlace the client in a high-Fowler's position將病人置於高福勒氏臥位
— Explanation · 中文詳解 —
低血容性休克的核心問題是循環血量不足，首要任務是建立大口徑靜脈通路（Large-bore IV）以進行快速輸液復甦。升壓劑（C）在補充血量前無效；高坐位（D）會導致回心血量減少，惡化休克；ECG（B）重要但非急救首要步驟，穩定循環動力學優先。
For hypovolemic shock, the priority is to initiate two large-bore IV catheters to allow for rapid fluid resuscitation and restoration of hemodynamic stability. Vasopressors are ineffective without adequate fluid volume, and high-Fowler's position can worsen shock by reducing venous return. Monitoring tools like ECG are secondary to immediate resuscitation efforts.
✦ 台美臨床差異
台灣臨床多由資深護理師或醫師建立靜脈通路，美國則鼓勵護理師在急救時依 protocol 第一時間建立通路。