# 一位開始服用 lisinopril 一週的個案回報嘴唇和舌頭腫脹。護理師應給予何種指示？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=397143&lang=zh-tw  
> language: zh-TW  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PPT

## 題目

一位開始服用 lisinopril 一週的個案回報嘴唇和舌頭腫脹。護理師應給予何種指示？

## 選項

1. 隨餐服用下一劑。
2. 使用市售漱口水。
3. 跳過一劑，明天再重新開始服藥。
4. 立即尋求緊急醫療照護。 **✔ 正確答案**

**正確答案: 4**

## 解析

服用 ACE 抑制劑時出現嘴唇和舌頭腫脹，暗示可能為血管性水腫，這可能威脅呼吸道。個案需要緊急評估。隨餐服藥、使用漱口水或稍後重新開始服藥，都無法處理緊急的呼吸道風險。

## 深入解析

臨床判斷
使用個案線索、時間點、檢驗數據和安全風險，來選擇最符合 ACE 抑制劑血管性水腫的回應。

記憶提示
將最強的線索群與最安全的護理判斷配對。

KR vs US
NCLEX 考題獎勵基於線索的優先思考，而非單獨的回憶。

## 臨床情境

臨床實務指引
對於 ACE 抑制劑血管性水腫，將完整的線索模式與個案當前的穩定性、醫囑數據和預期的護理範圍進行比較。

注意
當完整情境改變了優先次序或安全性時，不要僅根據單一線索選擇行動。

## 重要概念

- **ACE 抑制劑** — 一類用於治療高血壓、心衰竭，並在某些個案中用於保護腎臟的藥物。
- **血管性水腫** — 可能涉及嘴唇、舌頭、喉嚨或呼吸道的深層腫脹。
- **呼吸道風險** — 一種可能損害通氣功能並需要緊急處理的狀況。

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