護理師正在收納一位疑似急性心肌梗塞（MI）的病人，病人主訴胸骨後壓榨性疼痛並輻射至左臂、盜汗及噁心。護理師應立即採取哪項措施？
A nurse is admitting a client with a suspected acute myocardial infarction (MI). The client reports crushing substernal chest pain radiating to the left arm, diaphoresis, and nausea. Which immediate action should the nurse take?
- AAdminister oxygen at 4 L/min via nasal cannula以鼻導管給予 4 L/min 氧氣
- BAdminister aspirin 325 mg chewable給予 325 mg 嚼碎阿斯匹靈
- CObtain a 12-lead electrocardiogram (ECG)✓ 正解進行 12 導程心電圖檢查 (ECG)
- DAdminister sublingual nitroglycerin給予舌下硝酸甘油
在疑似急性心肌梗塞的病人身上，最優先的診斷工具是 12 導程心電圖（ECG），它能快速識別心肌缺氧或梗塞的類型，指導後續治療。給予氧氣、硝酸甘油、阿斯匹靈都是重要措施，但 ECG 診斷價值最高，應立即執行。
For a client with suspected acute myocardial infarction, obtaining a 12-lead electrocardiogram (ECG) is the priority action to confirm the diagnosis and determine the type of MI. While administering oxygen, aspirin, and nitroglycerin are important interventions, the ECG provides essential diagnostic information that guides subsequent treatment decisions.
在美國，標準的 AMI 處置流程通常包含「Door-to-ECG time」的時限要求；台灣的醫院也重視此時效性，但實際執行可能受病人量和檢傷分級影響。