# 個案在服用大量 acetaminophen 兩小時後抵達急診。個案清醒，主訴噁心。護理師應預期哪項醫囑？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=394049&lang=zh-tw  
> language: zh-TW  
> subject: Medication Administration  
> category: PPT

## 題目

個案在服用大量 acetaminophen 兩小時後抵達急診。個案清醒，主訴噁心。護理師應預期哪項醫囑？

## 選項

1. 再給一劑 acetaminophen 以緩解頭痛。
2. 依醫囑給予 acetylcysteine。 **✔ 正確答案**
3. 延遲治療直到出現黃疸。
4. 鼓勵高蛋白飲食以保護肝臟。

**正確答案: 2**

## 解析

Acetaminophen 過量可能導致嚴重肝損傷，acetylcysteine 是指徵存在時的解毒劑。治療不應等到出現黃疸等晚期徵象。給予更多 acetaminophen 或依賴飲食是不安全的。

## 深入解析

臨床判斷
在 acetaminophen 過量時，早期解毒劑治療具有時間敏感性。

記憶提示
Acetaminophen 過量：想到 acetylcysteine。

## 臨床情境

臨床實務指引
中毒照護優先考慮攝入時間、劑量、血清濃度檢測時機，以及指徵存在時的解毒劑治療。

注意事項
肝損傷可能延遲發生，因此沒有黃疸並不代表個案是安全的。

## 重要概念

- **Acetaminophen** — 一種止痛解熱劑，過量時可能導致肝毒性。
- **Acetylcysteine** — 一種用於減少 acetaminophen 過量後肝損傷的解毒劑。
- **肝毒性** — 藥物或毒素相關的肝損傷。

## 相同主題題目

- [An older adult with heart failure is scheduled to receive digoxin. The apical pulse is 54/…](https://mymerci.kr/pages/nclex_q.php?qn_id=393662&lang=zh-tw)
- [An older adult with heart failure is scheduled to receive digoxin. The apical pulse is 54/…](https://mymerci.kr/pages/nclex_q.php?qn_id=393663&lang=zh-tw)
- [A hospitalized client has a blood glucose of 118 mg/dL and is prescribed rapid-acting insu…](https://mymerci.kr/pages/nclex_q.php?qn_id=393722&lang=zh-tw)
- [A client taking lithium reports vomiting, coarse hand tremors, and new confusion. Which ac…](https://mymerci.kr/pages/nclex_q.php?qn_id=394021&lang=zh-tw)
- [A client taking lithium reports vomiting, coarse hand tremors, and new confusion. Which ac…](https://mymerci.kr/pages/nclex_q.php?qn_id=394022&lang=zh-tw)
- [A postoperative client who received IV morphine is difficult to arouse. Respirations are 7…](https://mymerci.kr/pages/nclex_q.php?qn_id=394070&lang=zh-tw)
- [A client uses an albuterol inhaler for wheezing and asks what side effect may occur. Which…](https://mymerci.kr/pages/nclex_q.php?qn_id=394106&lang=zh-tw)
- [The nurse teaches a client about insulin glargine. Which statement by the client indicates…](https://mymerci.kr/pages/nclex_q.php?qn_id=394115&lang=zh-tw)

## 以其他語言閱讀

- [en](https://mymerci.kr/pages/nclex_q.php?qn_id=394049&lang=en)
- [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=394049&lang=ko)
- [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=394049&lang=ja)
- [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=394049&lang=zh-tw)
- [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=394049&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。_