— 照護管理 · HARD · SATA —
病人使用新抗生素後出現過敏性休克徵象，應採取哪些行動？（選所有適合的）
A client is experiencing signs of anaphylaxis after receiving a new antibiotic. Which actions are required? (Select all that apply.)
- AStop the antibiotic infusion immediately✓ 正解立即停止抗生素輸注
- BAdminister epinephrine as prescribed✓ 正解依醫囑給予腎上腺素
- CElevate the head of the bed to 90 degrees將床頭抬高至90度
- DMaintain patent airway and provide oxygen✓ 正解維持呼吸道通暢並提供氧氣
- EMonitor blood pressure and pulse✓ 正解監測血壓與脈搏
— Explanation · 中文詳解 —
過敏性休克處理順序：停藥、呼叫支援、給予腎上腺素（Epinephrine）、確保呼吸道通暢（給氧）、監測生命徵象。床頭不應直立至 90 度，若病人有低血壓，應採平躺或抬高下肢，以增加回心血量並維持大腦灌流。
The priority interventions for anaphylaxis include stopping the offending agent, administering epinephrine, maintaining a patent airway with oxygen, and continuously monitoring vital signs. Elevating the head of the bed to 90 degrees is contraindicated because it can precipitate circulatory collapse in hypotensive clients; instead, the client should be placed supine with legs elevated to improve venous return.
✦ 台美臨床差異
美護理師擁有緊急給藥的 Standing Order；台灣護理師在給藥前通常需由醫師開立或緊急口頭醫囑。