# 一名64歲MI後3天的病患BP 84/62、HR 124、心音遙遠、JVD、奇異性脈搏16 mm Hg。心電圖為窄QRS竇性心搏過速。護理師的優先介入為何？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=372747&lang=zh-tw  
> language: zh-TW  
> subject: Complications of Procedures  
> category: ROR

## 題目

一名64歲MI後3天的病患BP 84/62、HR 124、心音遙遠、JVD、奇異性脈搏16 mm Hg。心電圖為窄QRS竇性心搏過速。護理師的優先介入為何？

## 選項

1. 為減少靜脈鬱血給予IV furosemide 40 mg。
2. 將病患置仰臥並立即準備插管。
3. 通知醫師，準備緊急心包穿刺，給予等張IV輸液bolus並供氧。 **✔ 正確答案**
4. 為減慢心率改善填充給予乙型阻斷劑。

**正確答案: 3**

## 解析

Beck三徵（低血壓、心音遙遠、JVD）＋奇異性脈搏>10 mm Hg＋近期MI為心包填塞。心包腔液體壓迫心臟限制舒張期填充，造成阻塞性休克。優先：通知醫師、準備緊急心包穿刺（根本治療）、IV輸液bolus增加前負荷、氧氣支持。利尿劑（1）降前負荷使填塞惡化。仰臥插管（2）未減壓使血流動力惡化。乙型阻斷劑（4）降HR與CO，為禁忌。

## 深入解析

心包填塞為心包腔液體壓迫心臟，限制舒張期填充並減少心輸出量的阻塞性休克。常見原因：心包炎、MI後自由壁破裂或Dressler症候群、惡性腫瘤、外傷、心臟手術後。特徵：Beck三徵（低血壓、心音遙遠、JVD）＋奇異性脈搏>10 mm Hg。奇異性脈搏為吸氣時SBP下降>10 mm Hg，以血壓計或動脈導管偵測 — 對誇張正常吸氣時左心室填充減少之疾病具特異性：填塞、嚴重氣喘、COPD惡化、張力性氣胸。心包穿刺為以心臟超音波或X光透視導引下subxiphoid或apical徑行心包液之緊急經皮引流 — 為填塞之根本治療。復發時行window或外科引流。

## 臨床情境

**64歲MI後3天**病患：**BP 84/62、HR 124、心音遙遠、JVD、奇異性脈搏16 mm Hg**。心電圖**窄QRS竇性心搏過速**。

## 重要概念

- **心包填塞** — 心包腔液體壓迫心臟，限制舒張期填充並減少心輸出量的阻塞性休克。常見原因：心包炎、MI後自由壁破裂或Dressler症候群、惡性腫瘤、外傷、心臟手術後。特徵：Beck三徵（低血壓、心音遙遠、JVD）＋奇異性脈搏>10 mm Hg。
- **奇異性脈搏** — 吸氣時SBP下降>10 mm Hg。以血壓計或動脈導管偵測。對誇張正常吸氣時左心室填充減少之疾病具特異性 — 填塞、嚴重氣喘、COPD惡化、張力性氣胸。
- **心包穿刺** — 以心臟超音波或X光透視導引下subxiphoid或apical徑行心包液之緊急經皮引流。填塞之根本治療。復發時行window或外科引流。

## 相同主題題目

- [A patient on mechanical ventilation has bilateral infiltrates on chest x-ray, no signs of …](https://mymerci.kr/pages/nclex_q.php?qn_id=372717&lang=zh-tw)
- [A 64-year-old patient is post-op day 6 from a small bowel resection. The nurse notes the a…](https://mymerci.kr/pages/nclex_q.php?qn_id=372799&lang=zh-tw)
- [A patient is 18 hours post-op from a tracheostomy. The patient suddenly coughs forcefully,…](https://mymerci.kr/pages/nclex_q.php?qn_id=372800&lang=zh-tw)
- [Fifteen minutes after a packed red blood cell transfusion begins, a client reports chills,…](https://mymerci.kr/pages/nclex_q.php?qn_id=393560&lang=zh-tw)
- [Fifteen minutes after a packed red blood cell transfusion begins, a client reports chills,…](https://mymerci.kr/pages/nclex_q.php?qn_id=393561&lang=zh-tw)
- [While turning a client with a chest tube, the drainage system disconnects from the chest t…](https://mymerci.kr/pages/nclex_q.php?qn_id=393680&lang=zh-tw)
- [While turning a client with a chest tube, the drainage system disconnects from the chest t…](https://mymerci.kr/pages/nclex_q.php?qn_id=393681&lang=zh-tw)
- [A client with suspected appendicitis is awaiting surgical evaluation. Which instruction is…](https://mymerci.kr/pages/nclex_q.php?qn_id=393882&lang=zh-tw)

## 以其他語言閱讀

- [en](https://mymerci.kr/pages/nclex_q.php?qn_id=372747&lang=en)
- [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=372747&lang=ko)
- [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=372747&lang=ja)
- [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=372747&lang=zh-tw)
- [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=372747&lang=vi)

---

More free questions: [NCLEX-RN 題庫](https://mymerci.kr/pages/nclex_bank.php?lang=zh-tw)

_僅供學習參考。實際臨床請遵循最新指引與所屬機構規範。_