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降低風險 · MEDIUM · MCQ

護理師照護一位剛完成支氣管鏡檢查的病人,下列哪項發現是護理師需優先評估的重點?

A nurse is caring for a client who has returned from a bronchoscopy. Which of the following findings is the priority for the nurse to assess?

  • AOxygen saturation
    氧氣飽和度
  • BPresence of gag reflex✓ 正解
    嘔吐反射的存在與否
  • CAbility to speak
    說話的能力
  • DThroat soreness
    咽喉疼痛
Explanation · 中文詳解

支氣管鏡檢查(Bronchoscopy)過程中,為了減輕病人不適與抑制咳嗽反射,會使用局部麻醉劑(如 Lidocaine)噴灑咽喉。這會暫時阻斷嘔吐反射(Gag reflex)。在反射恢復前,病人若飲水或進食,極易導致吸入性肺炎(Aspiration pneumonia)。因此,確保氣道保護機制恢復是術後護理的首要安全評估重點,此為 ABC(氣道、呼吸、循環)原則中的 Airway 安全維護。

During bronchoscopy, a topical anesthetic (such as lidocaine) is sprayed on the throat to reduce discomfort and suppress the cough reflex. This temporarily blocks the gag reflex. Before the reflex returns, drinking or eating may easily lead to aspiration pneumonia. Therefore, ensuring restoration of airway protective mechanisms is the priority postoperative safety assessment, consistent with the 'Airway' component of the ABC (airway, breathing, circulation) principle.

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