# 一位術後接受靜脈注射 morphine 的個案難以喚醒。呼吸速率為 7 次/分鐘，血氧飽和度為 86%。護理師應首先採取哪項行動？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=394070&lang=zh-tw  
> language: zh-TW  
> subject: Medication Administration  
> category: PPT

## 題目

一位術後接受靜脈注射 morphine 的個案難以喚醒。呼吸速率為 7 次/分鐘，血氧飽和度為 86%。護理師應首先採取哪項行動？

## 選項

1. 刺激個案、支持呼吸，並準備給予 naloxone。 **✔ 正確答案**
2. 記錄此為預期中的鎮靜狀態，並於 1 小時後重新評估。
3. 給予下一劑鴉片類藥物以預防反彈性疼痛。
4. 將個案平放並關閉氧氣。

**正確答案: 1**

## 解析

使用鴉片類藥物後出現嚴重鎮靜伴隨呼吸抑制是緊急情況。護理師應刺激個案、支持呼吸道和呼吸、視需要給予氧氣，並根據方案或醫囑準備 naloxone。延遲照護或給予更多鴉片類藥物是不安全的。

## 深入解析

臨床判斷
鴉片類藥物安全首要考量是呼吸安全。

記憶提示
使用鴉片類藥物後呼吸速率過低：呼吸道、呼吸、naloxone。

## 臨床情境

臨床實務指引
鴉片類藥物監測包括鎮靜程度、呼吸速率、氧合狀態、疼痛控制，以及逆轉呼吸抑制的準備。

注意事項
當呼吸嚴重受抑制時，切勿等待。

## 重要概念

- **Morphine** — 一種可能抑制呼吸的鴉片類止痛藥。
- **Naloxone** — 一種用於逆轉鴉片類藥物嚴重作用的拮抗劑。
- **呼吸抑制 (Respiratory Depression)** — 以呼吸緩慢或無效為表現的通氣不足。

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