# 第 5 階段——採取行動。病童僅有極微弱反應，且儘管給予氧氣，SpO2 仍降至 84%。請將護理措施依優先順序排列。

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=568574&lang=zh-tw  
> language: zh-TW  
> subject: Management of Care  
> category: MOC

## 題目

第 5 階段——採取行動。病童僅有極微弱反應，且儘管給予氧氣，SpO2 仍降至 84%。請將護理措施依優先順序排列。

準備並協助放置進階呼吸道及機械通氣

在支持措施建立後，重新評估呼吸音、氧合、通氣及神經學狀態

打開呼吸道，給予高濃度氧氣，並以甦醒球面罩支持通氣

啟動緊急應變並請求小兒呼吸道與重症照護團隊

持續心肺監測，並於團隊準備時建立血管路徑

## 解析

啟動專家協助，立即維持呼吸道與通氣，協助確立呼吸道處置，於應變過程中持續監測並建立血管路徑，再評估生理反應。

## 深入解析

快速解答
呼叫小兒呼吸道團隊，立即支持通氣，協助確立呼吸道處置，維持監測與管路，再重新評估。

為何正確
僅有極微弱反應且缺氧惡化，代表病童無法再等待下一個常規給藥週期。緊急求助與甦醒球面罩通氣可立即處理 ABC 威脅，同時團隊建立安全呼吸道。

簡易類比或心像
建立救援鏈：召集團隊、立即讓空氣進入、確保呼吸道、維持監測與管路通暢，再確認這條鏈是否恢復氧合與通氣。

記憶口訣
呼叫、通氣、確保、監測、再評估。

NCLEX 決策規則
當出現呼吸衰竭時，應先支持通氣再進行非緊急檢查；每次救命處置後皆須重新評估。

其他選項為何錯誤
若先從再評估、建立 IV 管路或準備設備著手，卻未先呼叫並進行通氣，將使立即性的呼吸道威脅未獲處理。

References
1GINA 2025 Strategy Report嚴重氣喘急性發作的辨識與緊急處置
2NHLBI: Asthma Attacks緊急警訊、緩解藥物使用、氧氣與通氣支持

## 臨床情境

病情更新
急性惡化——病童僅有極微弱反應，呼吸音幾乎聽不見，且儘管給予氧氣仍持續缺氧。

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