— 照護管理 · HARD · MCQ —
護理師照顧一位持有 DNR 指示的病人，病人突然心跳停止，護理師的第一個行動為何？
A nurse is caring for a client with a do-not-resuscitate (DNR) order. The client goes into cardiac arrest. What is the nurse's first action?
- ACheck the client for a pulse and respirations✓ 正解檢查病人是否有脈搏和呼吸
- BConsult the family regarding the DNR order就 DNR 指示諮詢家屬
- CAdminister epinephrine as per standing orders依既定醫囑給予腎上腺素
- DCall for the code team immediately立即呼叫復甦小組
— Explanation · 中文詳解 —
臨床發生突發狀況時，首要永遠是評估病人狀況（ABC）。雖然有 DNR 指示，但護理師必須確認病人是否真的心肺停止，而非單憑監測器警報。確認無生命徵象後，應依據院方政策通知醫師宣告死亡或執行舒適護理，而不應啟動復甦團隊。
In any emergency situation, the nurse's first action is always to assess the patient's status according to ABCs. Even with a DNR order, the nurse must verify the absence of a pulse and respirations to confirm clinical death rather than relying solely on monitor alarms, after which they follow facility policy for comfort care or pronouncement of death.
✦ 台美臨床差異
美台皆強調護理師需確認 DNR 有效性；台灣臨床有時會因家屬壓力而在 DNR 病人身上猶豫，美國則法律保障明確。