— 生理適應 · MEDIUM · MCQ —
一位 55 歲高血壓病患主訴劇烈胸骨後疼痛，觀察到盜汗及心搏過速。哪項護理措施為最高優先級？
A 55-year-old client with a history of hypertension reports severe substernal chest pain. The nurse observes diaphoresis and tachycardia. Which intervention is the highest priority?
- AObtain a 12-lead ECG取得12導程心電圖
- BObtain a focused cardiac history進行重點式心臟病史詢問
- CAdminister sublingual nitroglycerin給予舌下硝酸甘油
- DAdminister supplemental oxygen✓ 正解給予補充氧氣
— Explanation · 中文詳解 —
針對懷疑心肌梗塞（Myocardial Infarction）的病人，護理師必須依循 ABC 原則（呼吸、循環）。心肌梗塞會導致心肌缺氧，給予補充氧氣（Supplemental oxygen）能提高動脈血氧飽和度，增加心肌的氧氣供應，這是改善缺氧狀況最直接的優先介入。隨後，護理師應立即進行心電圖監測、給予硝酸甘油（Nitroglycerin）與阿斯匹靈等藥物，以減緩心肌損傷。
Administering supplemental oxygen is the highest priority to increase myocardial oxygenation and address tissue hypoxia associated with suspected myocardial infarction. This intervention aligns with the ABC (Airway, Breathing, Circulation) framework, ensuring adequate oxygen delivery before diagnostic tests or other medications are administered.