— 降低風險 · HARD · MCQ —
一位病人呈現低血容積休克徵象，哪項護理措施為最高優先級？
A client presents with signs of hypovolemic shock. Which nursing intervention is the highest priority?
- AInitiate large-bore intravenous access✓ 正解建立大口徑靜脈通道
- BInsert a Foley catheter插入導尿管
- CObtain vital signs every hour每小時測量生命徵象
- DAdminister pain medication給予止痛藥物
— Explanation · 中文詳解 —
低血容積休克的核心問題是灌流不足，建立大口徑靜脈通道（large-bore IV）是為了迅速補充液體與血液製品。這不僅是治療的基礎，也是維持血液動力學穩定的關鍵。其餘選項雖重要，但相較於建立靜脈通路進行復甦，優先級較低。
Hypovolemic shock results from inadequate tissue perfusion due to fluid loss, making rapid volume replacement the priority. Establishing large-bore intravenous access allows for the quick administration of crystalloids and blood products to stabilize hemodynamics. While monitoring output, vital signs, and managing pain are important, restoring circulatory volume takes precedence.
✦ 台美臨床差異
美國護理師在急診/加護病房多有授權在休克情況下先行建立靜脈通路；台灣需確認醫囑，但緊急危急情況下符合 ACLS 流程。