# 一名因高血壓開始服用 lisinopril 的個案表示嘴唇與舌頭腫脹且吞嚥困難。護理師第一步應做什麼？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=393678&lang=zh-tw  
> language: zh-TW  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PPT

## 題目

一名因高血壓開始服用 lisinopril 的個案表示嘴唇與舌頭腫脹且吞嚥困難。護理師第一步應做什麼？

## 選項

1. 評估氣道、暫停藥物並立即通知醫療人員。 **✔ 正確答案**
2. 教導乾咳是 lisinopril 的預期效果。
3. 建議下一劑與食物一起服用。
4. 安排一週後例行血壓檢查。

**正確答案: 1**

## 解析

嘴唇與舌頭腫脹加上吞嚥困難，提示 ACE 抑制劑相關嚴重不良反應血管性水腫。優先是評估氣道、暫停藥物並立即通知醫療人員。乾咳雖常見，但無法解釋腫脹與吞嚥困難。

## 深入解析

臨床判斷
藥物反應造成的氣道症狀優先於例行血壓追蹤。

記憶重點
ACE 抑制劑加嘴唇或舌頭腫脹等於氣道風險。

## 臨床情境

實務指引
ACE 抑制劑可能造成嘴唇、舌頭或氣道血管性水腫。疑似氣道受威脅需緊急評估與升級處理。

注意
不要把臉部或舌頭腫脹視為輕微過敏。

## 重要概念

- **Lisinopril** — 用於高血壓與心衰竭的 ACE 抑制劑，嚴重不良反應可能包括血管性水腫。
- **血管性水腫** — 深層皮膚或黏膜快速腫脹，若影響嘴唇、舌頭或喉嚨可威脅氣道。
- **氣道評估** — 立即評估呼吸、聲音、吞嚥、舌頭腫脹與阻塞徵象。

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