# 一位護理師正在照顧一位78歲末期心衰竭且正處於臨終階段的個案。個案無反應，呼吸速率為8次/分鐘且有呼吸暫停期，並可聽見上呼吸道分泌物聲音。家屬在床邊，要求盡一切可能讓個案舒適。護理師應採取哪些措施？請選出所有正確選項。

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=505798&lang=zh-tw  
> language: zh-TW  
> subject: Basic Care and Comfort  
> category: BCC

## 題目

一位護理師正在照顧一位78歲末期心衰竭且正處於臨終階段的個案。個案無反應，呼吸速率為8次/分鐘且有呼吸暫停期，並可聽見上呼吸道分泌物聲音。家屬在床邊，要求盡一切可能讓個案舒適。護理師應採取哪些措施？請選出所有正確選項。

1

依處方給予嗎啡以緩解呼吸困難和疼痛。

2

每15分鐘深度抽吸口咽部。

3

使用濕潤海綿頻繁提供口腔護理。

4

將個案翻身至側臥姿勢。

5

每小時測量生命徵象以偵測變化。

6

鼓勵家屬與個案說話及觸摸個案。

## 解析

給予處方嗎啡可緩解臨終常見的呼吸困難和疼痛。使用濕潤海綿頻繁進行口腔護理可維持舒適並預防口腔黏膜乾燥。翻身至側臥姿勢可減少吵雜的呼吸音並促進舒適。鼓勵家屬陪伴與互動可支持情緒與靈性安適。深度抽吸不適用，因為當分泌物未阻塞呼吸道時，可能造成不適與傷害，且無明確益處。每小時測量生命徵象會造成負擔且無助於舒適，在臨終階段應盡量減少監測。

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