# 一位個案預定接受侵入性處置。護理師發現個案在簽署同意書前已接受靜脈注射 midazolam。護理師應採取何項行動？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=397300&lang=zh-tw  
> language: zh-TW  
> subject: Informed Consent  
> category: MOC

## 題目

一位個案預定接受侵入性處置。護理師發現個案在簽署同意書前已接受靜脈注射 midazolam。護理師應採取何項行動？

## 選項

1. 停止同意程序並通知處置團隊。 **✔ 正確答案**
2. 立即要求個案的成年子女簽署同意書。
3. 見證簽名，因為個案仍清醒。
4. 記錄因已排定處置而推定同意。

**正確答案: 1**

## 解析

知情同意必須出於自願，並在鎮靜藥物損害決策能力前取得。護理師應停止程序並通知處置團隊，以便處理有效的同意。家屬簽名、推定同意或在鎮靜後見證均無法保護個案的自主權。

## 深入解析

臨床判斷
使用個案線索、時間點、檢驗數據及安全風險，選擇最符合「鎮靜後同意」情境的回應。

記憶提示
將最強的線索群組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，而非單獨的記憶。

## 臨床情境

臨床實務指引
對於「鎮靜後同意」，將完整的線索模式與個案當前的穩定性、醫囑數據及預期的護理範圍進行比較。

注意
當完整情境改變了優先順序或安全性時，切勿僅根據單一線索選擇行動。

## 重要概念

- **知情同意** — 在了解處置、風險、益處及替代方案後，所給予的自願許可。
- **程序性鎮靜** — 由藥物引起的意識降低，可能損害決策能力。
- **見證人** — 根據政策，確認簽名是自願完成的人。

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