# 第 5 階段 — 採取行動。開始給予硫酸鎂二十分鐘後，請根據每項發現最直接支持的問題將其分類。 > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=568580&lang=zh-tw > language: zh-TW > subject: Pharmacological and Parenteral Therapies > category: PPT ## 題目 第 5 階段 — 採取行動。開始給予硫酸鎂二十分鐘後，請根據每項發現最直接支持的問題將其分類。 **1.** 呼吸速率 10/min Select a category Supports uncontrolled severe preeclampsia Supports magnesium toxicity or accumulation Currently reassuring but not sufficient to stop surveillance **2.** 膝反射消失 Select a category Supports uncontrolled severe preeclampsia Supports magnesium toxicity or accumulation Currently reassuring but not sufficient to stop surveillance **3.** 過去一小時尿量 15 mL Select a category Supports uncontrolled severe preeclampsia Supports magnesium toxicity or accumulation Currently reassuring but not sufficient to stop surveillance **4.** 血壓 164/110 mm Hg Select a category Supports uncontrolled severe preeclampsia Supports magnesium toxicity or accumulation Currently reassuring but not sufficient to stop surveillance **5.** 持續嚴重頭痛 Select a category Supports uncontrolled severe preeclampsia Supports magnesium toxicity or accumulation Currently reassuring but not sufficient to stop surveillance **6.** SpO2 96% 合併令人安心的胎兒監測圖形 Select a category Supports uncontrolled severe preeclampsia Supports magnesium toxicity or accumulation Currently reassuring but not sufficient to stop surveillance ## 解析 呼吸抑制、反射消失和少尿支持鎂蓄積或中毒。持續嚴重壓力和頭痛顯示未控制的嚴重子癇前症。正常的血氧飽和度和目前令人安心的胎兒監測圖形不能消除其他緊急發現。 ## 深入解析 快速解答 呼吸、反射和尿量的發現指向鎂中毒，而嚴重壓力和頭痛顯示子癇前症仍未受控制。 為何此為正確 鎂經由腎臟清除，因此少尿可能導致蓄積。呼吸抑制和深腱反射消失是中毒警示，需要停止輸注、支持呼吸、通知團隊，並準備處方解毒劑，同時治療嚴重高血壓。 簡單類比或心像 使用兩個紅色資料夾：一個用於藥物蓄積，一個用於疾病仍在進展。令人安心的血氧數值或胎兒監測圖形不屬於任何一個紅色資料夾，但無法關閉它們。 記憶訣竅 低尿量、反射消失、低呼吸：停止鎂並升級處置。 NCLEX 決策規則 當輸注鎂時，檢查呼吸、反射和尿量；若出現中毒線索，在恢復任何輸注前停止暴露並支持 ABCs。 為何其他選擇是錯誤的 正常的血氧飽和度和暫時令人安心的胎兒監測圖形不能使呼吸抑制、少尿、嚴重高血壓或神經學症狀變得安全。 References 1ACOG Practice Bulletin 222: Gestational Hypertension and PreeclampsiaUrgent blood-pressure control, magnesium monitoring, and severe-feature management; reaffirmed 2026 ## 臨床情境 病情更新 新資料 — RR 為 10/min，膝反射消失，過去一小時尿量為 15 mL，BP 為 164/110 mm Hg，嚴重頭痛持續。SpO2 為 96%，胎兒監測圖形現呈中度變異性，無減速。 ## 相同主題題目 - [A nurse is programming a high-alert IV medication on a smart infusion pump. Which actions …](https://mymerci.kr/pages/nclex_q.php?qn_id=372863&lang=zh-tw) - [A patient has a serum potassium of 2.8 mEq/L and a new order for IV potassium chloride 40 …](https://mymerci.kr/pages/nclex_q.php?qn_id=373128&lang=zh-tw) - [A patient on chronic phenytoin for seizure disorder reports new diplopia and unsteady gait…](https://mymerci.kr/pages/nclex_q.php?qn_id=373129&lang=zh-tw) - [A patient on day 2 of total parenteral nutrition (TPN) has a capillary glucose of 248 mg/d…](https://mymerci.kr/pages/nclex_q.php?qn_id=373881&lang=zh-tw) - [A nurse is teaching a patient newly started on metoprolol 25 mg twice daily for hypertensi…](https://mymerci.kr/pages/nclex_q.php?qn_id=374879&lang=zh-tw) - [A patient post-radical cystectomy with ileal conduit urinary diversion is being taught uro…](https://mymerci.kr/pages/nclex_q.php?qn_id=374924&lang=zh-tw) - [A nurse is teaching a patient discharged on oral potassium chloride (extended-release tabl…](https://mymerci.kr/pages/nclex_q.php?qn_id=374939&lang=zh-tw) - [A 72-year-old on chronic warfarin for atrial fibrillation comes for routine follow-up. Aft…](https://mymerci.kr/pages/nclex_q.php?qn_id=374949&lang=zh-tw) ## 以其他語言閱讀 - [en](https://mymerci.kr/pages/nclex_q.php?qn_id=568580&lang=en) - [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=568580&lang=ko) - [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=568580&lang=ja) - [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=568580&lang=zh-tw) - [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=568580&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。_