— 照護管理 · MEDIUM · MCQ —
病人持有 DNR（不施行心肺復甦術）醫囑。病人停止呼吸。護理師的立即行動為何？
A nurse is caring for a client who has a DNR (Do Not Resuscitate) order. The client stops breathing. What is the nurse's immediate action?
- ANotify the family before doing anything.在採取任何行動前先通知家屬
- BBegin chest compressions immediately.立即開始胸部按壓
- CCall the code team.呼叫急救小組
- DAssess for a carotid pulse and verify the DNR order is current.✓ 正解評估頸動脈脈搏並確認 DNR 醫囑為有效期限內
— Explanation · 中文詳解 —
DNR（Do Not Resuscitate）醫囑僅針對心肺復甦術（CPR）的執行，並不代表放棄所有照護。若病人停止呼吸，護理師應立即評估脈搏並確認 DNR 醫囑的有效性。若確認病人無呼吸且無脈搏，且 DNR 指示明確，則無需啟動 CPR 與呼叫急救小組（Code team）。若 DNR 指示不適用或無效，則應立即啟動急救機制。這是護理師在法律與倫理上的專業責任。
A DNR order specifically prohibits cardiopulmonary resuscitation (CPR) but does not mean all care is withheld. Upon finding the client unresponsive and not breathing, the nurse must first assess for a pulse and verify that the DNR order is current and applicable before deciding not to initiate resuscitation efforts.
✦ 台美臨床差異
在美國，DNR 醫囑需由醫師簽署並納入病歷，護理師需確保 DNR 狀態在當下仍有效（Current）。若病人轉院或狀況改變，DNR 醫囑可能需要重新簽署或確認，這是護理師在法律安全上的重要查核點。