— 照護管理 · HARD · MCQ —
一位病人突然發生胸痛，護理師的首要行動為何？
A nurse is caring for a client who is experiencing a sudden onset of chest pain. Which of the following is the nurse's first action?
- AObtain a 12-lead ECG取得十二導程心電圖
- BNotify the healthcare provider通知醫療保健提供者
- CAssess the client's vital signs✓ 正解評估病人的生命徵象
- DAdminister oxygen as per protocol依規定給予氧氣
— Explanation · 中文詳解 —
處理胸痛的標準流程為「評估、介入、回報」。首先需評估生命徵象以確立病人的血液動力學穩定度。雖需執行心電圖與氧氣治療，但未先行評估生命徵象即進行處置或通知醫師，會缺乏判斷病人危急程度的臨床依據。穩定生命徵象與掌握數據是判斷心肌梗塞流程的基礎。
The nurse's first action is to assess the client's vital signs to determine hemodynamic stability and establish a baseline for further intervention. While obtaining an ECG and administering oxygen are critical steps, they should follow the initial assessment to guide appropriate clinical decision-making and provider notification.
✦ 台美臨床差異
美式教學強調評估優先，台灣臨床習慣在評估同時即進行後續作業（如心電圖）。