# 護理師進入術後個案的病房，發現配偶在個案睡著時反覆按壓PCA按鈕。個案的POSS量表為3分（經常嗜睡），呼吸速率為每分鐘9次。優先的護理措施為何？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=375172&lang=zh-tw  
> language: zh-TW  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PA

## 題目

護理師進入術後個案的病房，發現配偶在個案睡著時反覆按壓PCA按鈕。個案的POSS量表為3分（經常嗜睡），呼吸速率為每分鐘9次。優先的護理措施為何？

## 選項

1. 在病歷記錄事件並依處方繼續PCA。
2. 調整lockout讓配偶可繼續按。
3. 稱讚配偶為病人爭取舒適。
4. 立即制止配偶、停止PCA、刺激並給氧、若呼吸抑制惡化準備naloxone、通知處方者與rapid response、完成事件報告、再衛教PCA-by-proxy為Joint Commission/ISMP禁止的sentinel event。 **✔ 正確答案**

**正確答案: 4**

## 解析

PCA由他人代按是指病人以外的人按下按鈕——包括家屬、訪客、善意朋友或未經授權的工作人員（所謂的護理人員控制止痛法不同，僅在特定協議下允許用於無法參與的病人，例如兒科或臨終照護，並需有明確醫囑）。PCA由他人代按已被聯合委員會列為警訊事件，有因累積性類鴉片過量導致死亡的報告。在此例中可辨識的警訊：POSS 3分且呼吸速率9次/分，表示即將發生類鴉片引起的呼吸抑制。優先措施：(1)立即停止他人代按，並以同理心解釋危險性，(2)停止PCA輸注以中止累積劑量，(3)刺激病人、給予氧氣、擺位維持呼吸道，持續監測呼吸速率、SpO2及POSS，(4)準備naloxone 0.04至0.4 mg靜脈注射，若呼吸抑制惡化（呼吸速率低於8次、無反應、SpO2下降）則依反應調整劑量；呼叫快速反應小組，(5)通知開立醫囑者以取得醫囑，並考慮轉換為非PCA模式，(6)完成醫院事件報告；後續追蹤包含對配偶、病人進行衛教及張貼警示標語。稱讚、調整鎖定時間或僅記錄，是不安全的。

## 深入解析

PCA-by-proxy屬sentinel event。停proxy、停PCA、處理氣道、備naloxone — 不能只記錄繼續。

## 重要概念

- **PCA-by-proxy sentinel event** — Joint Commission列為sentinel event，有累積過量死亡，需立即停止
- **POSS 3 + RR 9** — 即將呼吸抑制的trigger，需備naloxone、刺激、給氧、啟動rapid response
- **event reporting** — sentinel/near-miss報告，促組織學習與防止再發，作為教學素材

## 相同主題題目

- [A nurse is reviewing the morning lab results for an adult client receiving warfarin for at…](https://mymerci.kr/pages/nclex_q.php?qn_id=360515&lang=zh-tw)
- [A client is admitted to the emergency department after ingesting an unknown amount of acet…](https://mymerci.kr/pages/nclex_q.php?qn_id=362720&lang=zh-tw)
- [A client with chronic heart failure is prescribed metoprolol 25 mg orally twice daily. Bef…](https://mymerci.kr/pages/nclex_q.php?qn_id=362756&lang=zh-tw)
- [A 28-year-old client with type 1 diabetes receives regular insulin 6 units and NPH insulin…](https://mymerci.kr/pages/nclex_q.php?qn_id=362792&lang=zh-tw)
- [A client receives IV vancomycin 1 g every 12 hours for MRSA bacteremia. Before the next do…](https://mymerci.kr/pages/nclex_q.php?qn_id=362833&lang=zh-tw)
- [A client with bipolar disorder has been taking lithium carbonate 600 mg orally three times…](https://mymerci.kr/pages/nclex_q.php?qn_id=362894&lang=zh-tw)
- [An 80-year-old male with heart failure is prescribed digoxin 0.125 mg daily. During mornin…](https://mymerci.kr/pages/nclex_q.php?qn_id=372686&lang=zh-tw)
- [A 38-year-old female with rheumatoid arthritis is being discharged with a new prescription…](https://mymerci.kr/pages/nclex_q.php?qn_id=372687&lang=zh-tw)

## 以其他語言閱讀

- [en](https://mymerci.kr/pages/nclex_q.php?qn_id=375172&lang=en)
- [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=375172&lang=ko)
- [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=375172&lang=ja)
- [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=375172&lang=zh-tw)
- [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=375172&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。_