— 基本照護與舒適 · HARD · MCQ —
護理師針對一位服用口服止痛藥且有慢性疼痛史的病人，應將何種評估發現列為優先？
Which assessment finding should the nurse recognize as a priority for a client with a history of chronic pain receiving oral analgesics?
- ARespiratory rate of 10 breaths per minute✓ 正解呼吸頻率為每分鐘 10 次
- BReported pain level of 4/10主觀疼痛程度為 4/10
- CConstipation for 3 days便秘 3 天
- DDrowsiness after taking the medication服藥後嗜睡
— Explanation · 中文詳解 —
呼吸頻率下降至每分鐘 10 次是鴉片類藥物導致呼吸抑制的危險訊號，屬於危及生命的 ABC 異常，必須優先處理。便秘是常見副作用但非即刻致命；疼痛評估重要，但需先確認生命徵象穩定。嗜睡為常見副作用，需密切監測，但嚴重度不及呼吸異常。
Proper body mechanics involve maintaining a wide base of support and keeping the client close to the nurse's center of gravity to ensure stability and reduce strain. Keeping the client close minimizes the lever arm, thereby decreasing stress on the nurse's lumbar spine during transfers. Conversely, bending at the waist, twisting the torso, or keeping the client's feet too close together increases the risk of injury to both the nurse and the client.
✦ 台美臨床差異
美國護理師對鴉片類藥物給藥前評估極為嚴格，台灣臨床則較常由醫師開立常規用藥。