# 情境 因發炎性腸道疾病服用prednisone 30 mg daily長達14個月的50歲個案於4天前藥物用盡。目前出現嚴重倦怠、嘔吐、腹痛、BP 80/48、HR 124、glucose 58 mg/dL、Na 128 mEq/L、K 5.8 mEq/L。護理師應準備執行的優先介入組合為何?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=375102&lang=zh-tw  
> language: zh-TW  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PA

## 題目

情境 因發炎性腸道疾病服用prednisone 30 mg daily長達14個月的50歲個案於4天前藥物用盡。目前出現嚴重倦怠、嘔吐、腹痛、BP 80/48、HR 124、glucose 58 mg/dL、Na 128 mEq/L、K 5.8 mEq/L。護理師應準備執行的優先介入組合為何?

## 選項

1. 建立兩條大口徑靜脈、hydrocortisone 100 mg IV push、NS 1 L bolus + D5W、連續心電圖監測並準備轉ICU。 **✔ 正確答案**
2. 對於噁心，給予ondansetron 4毫克靜脈注射；嘔吐解決後，重新開始口服prednisone 30毫克每日一次；並安排於一週內與主要照護提供者進行追蹤。
3. 將個案禁食，給予0.9%氯化鈉注射液每小時75毫升，並安排緊急腹部和骨盆電腦斷層掃描(對比劑顯影)以評估是否有阻塞或穿孔。
4. 給予10單位短效胰島素靜脈推注及50毫升50%葡萄糖液，然後每30分鐘重新評估血清鉀和血糖，直到數值恢復正常。

**正確答案: 1**

## 解析

臨床表現為HPA軸被抑制患者長期高劑量prednisone突然停藥誘發的急性腎上腺(愛迪生氏)危機。診斷線索：對輸液無反應的低血壓、低血糖、低鈉、高鉀、低血容、心搏過速加上類固醇用藥史與漏服。優先介入順序：(1) 建立兩條大口徑靜脈並立即給hydrocortisone 100 mg IV bolus(之後每6小時50~100 mg或24小時持續200 mg)；(2) NS 1 L IV bolus視需要重複加D5W校正低血糖；(3) 連續心電圖加12導程ECG(高K+低血容+低血壓增加心律不整風險)；(4) 準備ICU入住；(5) 找出並治療誘因(常為漏服、感染、手術、創傷)。僅重新口服prednisone因嘔吐及休克生理而不足。胰島素可降鉀，但優先為類固醇補充，其本身能矯正鈉、血糖、鉀及血流動力。停藥及CT會延誤治療。

## 深入解析

腎上腺危機需同時施行IV hydrocortisone、NS+D5W及ICU監測，非依序處理。NCLEX陷阱為單獨處理高鉀或低血糖；類固醇補充才能解決生理根源。

## 重要概念

- **addisonian crisis** — 急性腎上腺危機，低血壓、低血糖、低鈉、高鉀，須立即IV類固醇加輸液加ICU
- **hydrocortisone 100 mg IV bolus** — 腎上腺危機首選藥，之後q6h或24小時持續200 mg輸注
- **NS + D5W bolus** — 5%葡萄糖含等張液同時校正低血容、低鈉與低血糖

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