— 藥理與非經腸給藥 · MEDIUM · MCQ —
一位使用 PCA 嗎啡止痛的病人，出現哪種評估結果需護理師立即介入？
Which assessment finding in a client receiving morphine sulfate via patient-controlled analgesia (PCA) requires immediate nursing intervention?
- ABlood pressure of 100/60 mmHg血壓 100/60 mmHg
- BRespiratory rate of 8 breaths per minute✓ 正解呼吸速率每分鐘 8 次
- CDrowsiness when undisturbed未受干擾時嗜睡
- DReport of itching sensations主訴搔癢感
— Explanation · 中文詳解 —
嗎啡（Morphine）是強效鴉片類止痛藥，其最嚴重的副作用為呼吸抑制（Respiratory depression）。當病人使用病人自控式止痛（PCA）時，護理師必須密切監測呼吸速率。呼吸速率低於 10 次/分屬於臨床危急值，暗示發生呼吸抑制，必須立即停止 PCA 並準備給予解毒劑 Naloxone。
Respiratory depression is the most serious adverse effect of morphine, requiring immediate intervention when the respiratory rate drops below 10 breaths per minute. While mild hypotension, drowsiness, and pruritus are common or expected side effects, a significantly low respiratory rate indicates potential overdose. The nurse must stop the PCA infusion and prepare to administer naloxone to reverse the opioid effects.