— 照護管理 · HARD · MCQ —
護理師在急診評估一位主訴嚴重胸痛並輻射至下顎的病人。護理師應先採取何項行動？
A nurse is assessing a client in the emergency department who reports severe chest pain radiating to the jaw. Which action should the nurse perform first?
- AObtain an EKG✓ 正解取得心電圖
- BAdminister morphine sulfate施用硫酸嗎啡
- CObtain a complete blood count取得全血細胞計數
- DAdminister aspirin 325 mg施用325毫克阿斯匹靈
— Explanation · 中文詳解 —
胸痛病人優先考慮急性心肌梗塞。依據 ACLS 指引，在確認生命徵象後，應立即執行 12 導程心電圖（EKG）以區分 STEMI 與 NSTEMI，這決定了後續是否需要立即進行經皮冠狀動脈介入治療（PCI）。雖然阿斯匹靈很重要，但心電圖提供的診斷資訊是制定緊急治療方針的關鍵。
For a client presenting with severe chest pain, obtaining an EKG is the priority to identify ST-segment elevation and distinguish between STEMI and NSTEMI. This diagnostic information is critical for determining the immediate need for reperfusion therapy such as PCI.
✦ 台美臨床差異
美國急診護理師依據 Standing Orders 可在醫師評估前執行 EKG；台灣通常亦有類似 Protocol，但仍需醫師快速確認。