— 藥理與非經腸給藥 · HARD · SATA —
護理師準備協助病人使用嗎啡 PCA 幫浦。下列哪些護理措施應包含在照護計畫中？（選所有適合的）
A nurse is preparing to administer morphine sulfate via PCA pump. Which of the following should be included in the care plan? (Select all that apply.)
- AAssess respiratory rate every 1-2 hours✓ 正解每 1-2 小時評估呼吸頻率
- BKeep naloxone available at the bedside✓ 正解在床邊備有納洛酮
- CInstruct the patient to press the button only when pain is severe指示患者在疼痛嚴重時才按壓按鈕
- DMonitor for the presence of pruritus✓ 正解監測是否有皮膚搔癢現象
- ECheck the machine settings with another nurse✓ 正解與另一位護理師檢查機器設定
— Explanation · 中文詳解 —
PCA 照護核心在於安全與監測。呼吸頻率是監控嗎啡抑制呼吸之關鍵指標。Naloxone 必須隨時備用以解毒。止癢（pruritus）是嗎啡常見副作用。機器設定為高風險步驟，依據病人安全規範需由兩位護理師核對。C 是錯誤的，應教育病人疼痛開始時即按壓，以維持穩定的血液濃度。
Respiratory depression is the most critical adverse effect of opioids, requiring frequent monitoring and keeping naloxone readily available as an antidote. Pruritus is a common non-allergic side effect, and independent double-checks of PCA pump settings are essential safety protocols to prevent medication errors.
✦ 台美臨床差異
美國醫院對 PCA 設定有嚴格的雙人核對制度，台灣臨床亦有類似規範，但自動化給藥系統與警示機制在美國較為普及。