— 生理適應 · MEDIUM · MCQ —
一位敗血症病人出現低血壓和心跳過速。護理師懷疑病人有血容量不足。應優先執行何項措施？
A client with sepsis is experiencing hypotension and tachycardia. The nurse suspects hypovolemia. Which intervention should be implemented first?
- AAdminister a broad-spectrum antibiotic給予廣效型抗生素
- BObtain blood cultures抽取血液培養
- CAdminister intravenous fluids✓ 正解給予靜脈輸液
- DAdminister a vasopressor給予血管收縮劑
— Explanation · 中文詳解 —
敗血症性休克（Septic shock）屬於分佈性休克，病理機轉為血管擴張與毛細血管滲漏，導致有效循環血量不足。根據敗血症照護指引（Surviving Sepsis Campaign），優先處理循環障礙至關重要。在病人出現低血壓（hypotension）與心跳過速（tachycardia）時，首要任務是透過大量靜脈輸液（fluid resuscitation）補充血容量，以維持組織灌流。
In septic shock, vasodilation and capillary leakage cause relative hypovolemia, making fluid resuscitation the immediate priority to restore circulating volume and tissue perfusion. Although antibiotics and blood cultures are essential components of sepsis management, stabilizing hemodynamics with intravenous fluids takes precedence when hypotension and tachycardia are present.