— 生理適應 · HARD · MCQ —
一位急性胰臟炎病人的血清鈣濃度為 7.2 mg/dL，護理師應優先採取的措施為何？
A client with acute pancreatitis presents with a serum calcium level of 7.2 mg/dL. Which nursing intervention is the highest priority?
- AMonitor cardiac rhythm via continuous ECG透過連續心電圖監測心律
- BMonitor for Chvostek's sign監測 Chvostek 徵象
- CAdminister IV calcium gluconate immediately立即靜脈注射葡萄糖酸鈣
- DPrepare for seizure precautions✓ 正解準備防癲癇措施
— Explanation · 中文詳解 —
低血鈣（< 8.5 mg/dL）最嚴重的併發症是喉頭痙攣導致呼吸道阻塞與神經系統過度興奮導致癲癇。雖然需監測 Chvostek 徵象與 ECG，但保護病人免受癲癇發作的傷害（Seizure precautions）是優先確保生命安全的護理介入。鈣劑給予需依據醫囑而非直接執行。
Severe hypocalcemia can lead to life-threatening complications such as laryngospasm and seizures, making seizure precautions the highest priority to ensure patient safety. While cardiac monitoring and assessing for Chvostek's sign are important, they do not directly prevent physical injury from a potential seizure event.
✦ 台美臨床差異
美國護理師常依據急救箱規範備妥藥物，台灣臨床醫師與護理師對藥物醫囑依賴性較高，需確保醫囑完整。