# 給藥前，護理長注意到一位護理師說話含糊、步態不穩且有酒味。護理長應首先採取哪項行動？ > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=498852&lang=zh-tw > language: zh-TW > subject: Adverse Effects/Contraindications/Interactions > category: MOC ## 題目 給藥前，護理長注意到一位護理師說話含糊、步態不穩且有酒味。護理長應首先採取哪項行動？ ## 選項 1. 將該護理師調離病人照護，並遵循機構的通報流程 **✔ 正確答案** 2. 請另一位護理師觀察給藥過程後再決定如何處理 3. 在指定的病人接受預定藥物後，讓該護理師回家 4. 在該護理師排定的班別結束後，私下討論觀察到的情況 **正確答案: 1** ## 解析 可觀察到的功能受損會立即造成病人安全風險。護理長應將該護理師調離執業，安排替代人力，記錄客觀觀察，並遵循機構的通報及適任評估流程。 ## 深入解析 快速解答 立即停止該受損護理師的病人照護職責，並啟動機構通報流程。 為什麼這是正確的 說話含糊、步態不穩及酒味是護理師可能不適合執業的客觀徵象。保護病人優先於調查原因；指定的主管及政策隨後引導評估、運送、記錄及通報。 簡單比喻或心智圖像 這就像在故障排除前，先將明顯故障的設備停用。護理師是有尊嚴及正當程序權利的人，因此此類比強調立即安全，而非定罪或診斷。 記憶掛鉤 功能受損徵象導致調離、安排替代、記錄及通報。 NCLEX 決策規則 當臨床人員出現客觀的功能受損徵象時，首先防止進一步的病人接觸。使用中立的觀察及既定的指揮鏈進行適任評估，而非診斷、對質或等待更多證據。 為什麼其他選項是錯的 給藥期間觀察會使病人暴露於風險。完成給藥延遲風險控制，而等到班別結束則延誤必要的安全應對。參考文獻 - [1]NCSBN: 2026 NCLEX-RN Test PlanNational Council of State Boards of Nursing - [2]Washington State Board of Nursing: CARES Guide for Colleagues Concerned About Substance UseWashington State Board of Nursing, 2025 ## 相同主題題目 - [A nurse is reviewing the morning lab results for an adult client receiving warfarin for at…](https://mymerci.kr/pages/nclex_q.php?qn_id=360515&lang=zh-tw) - [A client is admitted to the emergency department after ingesting an unknown amount of acet…](https://mymerci.kr/pages/nclex_q.php?qn_id=362720&lang=zh-tw) - [A client with chronic heart failure is prescribed metoprolol 25 mg orally twice daily. Bef…](https://mymerci.kr/pages/nclex_q.php?qn_id=362756&lang=zh-tw) - [A 28-year-old client with type 1 diabetes receives regular insulin 6 units and NPH insulin…](https://mymerci.kr/pages/nclex_q.php?qn_id=362792&lang=zh-tw) - [A client receives IV vancomycin 1 g every 12 hours for MRSA bacteremia. Before the next do…](https://mymerci.kr/pages/nclex_q.php?qn_id=362833&lang=zh-tw) - [A client with bipolar disorder has been taking lithium carbonate 600 mg orally three times…](https://mymerci.kr/pages/nclex_q.php?qn_id=362894&lang=zh-tw) - [An 80-year-old male with heart failure is prescribed digoxin 0.125 mg daily. During mornin…](https://mymerci.kr/pages/nclex_q.php?qn_id=372686&lang=zh-tw) - [A 38-year-old female with rheumatoid arthritis is being discharged with a new prescription…](https://mymerci.kr/pages/nclex_q.php?qn_id=372687&lang=zh-tw) ## 以其他語言閱讀 - [en](https://mymerci.kr/pages/nclex_q.php?qn_id=498852&lang=en) - [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=498852&lang=ko) - [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=498852&lang=ja) - [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=498852&lang=zh-tw) - [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=498852&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。_