還有更多這樣的題目挑戰 ›

4階段 — 產生解決方案。選出所有適用於目前呼吸、鉀輸注和抗凝血風險的措施。

Select All That Apply

選擇作答後，查看答案。

1 Resume PCA demand dosing because there is no basal infusion and the delivered amount remains below the programmed four-hour limit, even though the family activated doses during sleep. 恢復 PCA 需求劑量，因為沒有基礎輸注，且即使家屬在個案睡眠期間啟動了劑量，給予的總量仍低於程式設定的四小時限制。 2 Stop PCA dosing, stay with the client, call for immediate assistance, assess and support airway and ventilation, and use protocol-directed naloxone if the response remains inadequate. 停止 PCA 給藥，留在個案身邊，呼叫立即協助，評估並支持呼吸道和通氣，如果反應仍不足，則依據規範使用納洛酮。 3 Stop the potassium infusion, assess and manage the painful peripheral site under policy, and ask the prescriber and pharmacist to reassess the remaining dose, concentration, and route. 停止鉀輸注，依據政策評估和處理疼痛的周邊輸注部位，並請處方醫師和藥師重新評估剩餘劑量、濃度和途徑。 4 Stop heparin, aspirin, and ticagrelor indefinitely before checking for bleeding or applying the heparin nomogram because any aPTT above the target proves major hemorrhage. 在檢查出血或應用肝素列線圖之前，無限期停止肝素、阿斯匹靈和替格瑞洛，因為任何高於目標值的 aPTT 都證明有大出血。 5 Verify the heparin order, pump, prior response, sample timing, and bleeding findings; obtain the due aPTT and follow the hospital nomogram for that result. 驗證肝素醫囑、幫浦、先前反應、檢體採檢時間和出血發現；取得應測的 aPTT 並依據該結果遵循醫院的列線圖。 6 After stabilization, secure the PCA button for patient-only use, perform family teach-back, reassess the analgesia plan, and document and report the proxy activation according to policy. 穩定後，將 PCA 按鈕固定為個案專屬使用，對家屬進行回覆示教，重新評估止痛計畫，並依據政策記錄和報告代理啟動的情況。

查看答案

相同主題的下一題A client is admitted to the emergency department after ingesting an unknown amount of acet…本題收錄於此題庫[전통+신유형] NCLEX LEVEL UP 패키지KRW 79,000

僅供學習參考。實際臨床請遵循最新指引與所屬機構規範。