# 一名GBS患者主訴無力加劇，其床邊肺活量（VC）在4小時內由22 mL/kg降至14 mL/kg。護理師應預期採取哪些處置？請選出所有適用者。

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=375096&lang=zh-tw  
> language: zh-TW  
> subject: Management of Care  
> category: MOC

## 題目

一名GBS患者主訴無力加劇，其床邊肺活量（VC）在4小時內由22 mL/kg降至14 mL/kg。護理師應預期採取哪些處置？請選出所有適用者。

1

實施機械與藥物性DVT預防

2

持續BP與ECG監測自主神經功能障礙

3

於急性呼吸衰竭前準備擇期插管

4

依醫囑啟動IVIG或血漿置換

5

因延髓性無力使用NIV作為決定性氣道

## 解析

GBS即將發生神經肌肉性呼吸衰竭的指標：VC低於15-20 mL/kg、最大吸氣負壓（NIF）比-25至-30 cmH2O更接近零（即負壓不足）、單次呼吸數小於20、咳嗽無力或延髓功能障礙。選擇性插管可預防緊急的呼吸道崩塌及吸入性肺炎。靜脈注射免疫球蛋白（IVIG，0.4 g/kg/day，連續5天）或血漿置換術為等效的疾病調節治療；類固醇並無助益。對於伴有延髓無力的GBS，通常避免使用非侵襲性通氣（NIV），因為有吸入性風險及進行性呼吸衰竭 — 傾向於確定性插管。自主神經功能異常（血壓波動、心律不整、腸阻塞）需持續監測。因臥床不動，必須採取深靜脈血栓（DVT）預防措施（連續充氣加壓裝置SCDs合併肝素）。

## 深入解析

記憶20/30/40:VC<20、NIF弱於-30、MIP不足即插管。Single breath count逐漸變弱為床邊快速趨勢。

## 臨床情境

NIF -22 cmH2O。Single breath count 12。SpO2 95%(室氣)。延髓性無力與咳嗽弱。

## 重要概念

- **肺活量(VC)** — 深吸後最大呼氣量 — 神經肌肉衰竭時下降。
- **IVIG** — 靜脈免疫球蛋白 — GBS首選治療,與血漿置換等效。
- **自主神經功能障礙** — 血壓波動、心律不整、GI改變 — GBS死因。

## 相同主題題目

- [A nurse is adopting the I-PASS structured handoff tool for end-of-shift report. Which elem…](https://mymerci.kr/pages/nclex_q.php?qn_id=372862&lang=zh-tw)
- [The night-shift nurse receives a telephone order from the on-call provider for "morphine 4…](https://mymerci.kr/pages/nclex_q.php?qn_id=373130&lang=zh-tw)
- [A nurse is preparing a patient for surgery later today. The provider has just left the roo…](https://mymerci.kr/pages/nclex_q.php?qn_id=373400&lang=zh-tw)
- [A 82-year-old presents to clinic with recent falls and worsening confusion. After reviewin…](https://mymerci.kr/pages/nclex_q.php?qn_id=373873&lang=zh-tw)
- [A nurse is caring for an agitated post-operative patient who is pulling at the IV and surg…](https://mymerci.kr/pages/nclex_q.php?qn_id=373880&lang=zh-tw)
- [Immediately before a bedside lumbar puncture, the nurse leads the team through the Univers…](https://mymerci.kr/pages/nclex_q.php?qn_id=373883&lang=zh-tw)
- [A patient with limited English proficiency arrives for discharge teaching with the family.…](https://mymerci.kr/pages/nclex_q.php?qn_id=374874&lang=zh-tw)
- [An alert and oriented patient with metastatic cancer states, "I do not want any more chemo…](https://mymerci.kr/pages/nclex_q.php?qn_id=374912&lang=zh-tw)

## 以其他語言閱讀

- [en](https://mymerci.kr/pages/nclex_q.php?qn_id=375096&lang=en)
- [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=375096&lang=ko)
- [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=375096&lang=ja)
- [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=375096&lang=zh-tw)
- [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=375096&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。_