— 藥理與非經腸給藥 · MEDIUM · SATA —
護理師準備給予病人硫酸嗎啡。需評估哪些項目?(選所有適合的)
A nurse is preparing to administer morphine sulfate to a client. Which of the following should the nurse assess? (Select all that apply.)
- ARespiratory rate✓ 正解呼吸頻率
- BBlood pressure✓ 正解血壓
- CPain level✓ 正解疼痛程度
- DBowel movement history✓ 正解排便歷史
- ECapillary refill time毛細血管再充盈時間
— Explanation · 中文詳解 —
嗎啡是強效鴉片類藥物,主要副作用包括呼吸抑制、低血壓、便秘。給藥前必須評估呼吸(安全性指標)、疼痛指數(療效指標)、血壓(副作用監測)。因鴉片藥物易導致腸蠕動變慢,故排便紀錄(E)也是長期用藥的評估重點。
Morphine sulfate requires assessment of respiratory rate, blood pressure, pain level, and bowel movement history prior to administration. These parameters address the drug's primary risks of respiratory depression and hypotension, confirm the need for analgesia, and monitor for common opioid-induced constipation.
✦ 台美臨床差異
美國醫院常見嗎啡給藥前評估單,台灣則多整合於護理紀錄中。