護理師評估一位疑似氣胸的病人。下列哪些臨床表徵是護理師應預期的？（選所有適合的）
A nurse is assessing a client with a suspected pneumothorax. Which clinical findings should the nurse expect? (Select all that apply.)
- AAbsent breath sounds on the affected side✓ 正解患側呼吸音消失
- BTracheal deviation toward the affected side氣管向患側偏移
- CSudden sharp chest pain✓ 正解突發性尖銳胸痛
- DHyperresonance on percussion of the affected area✓ 正解患側叩診呈過度共鳴音
- EIncreased respiratory rate✓ 正解呼吸頻率增加
氣胸（Pneumothorax）導致肋膜腔內壓力改變。空氣堆積會阻礙肺部擴張，造成患側呼吸音消失與叩診呈現過度共鳴（Hyperresonance）。病人的呼吸代償機制會導致呼吸急促，且常合併突發性銳利胸痛。氣管偏移（B）通常發生於張力性氣胸且偏向「健側」而非患側，故 B 選項錯誤。
Pneumothorax alters pressure within the pleural cavity. The accumulation of air impairs lung expansion, leading to absent breath sounds on the affected side and hyperresonance on percussion. The patient's respiratory compensatory mechanism produces tachypnea, often accompanied by sudden, sharp chest pain. Tracheal deviation (B) usually occurs in tension pneumothorax and shifts toward the unaffected side rather than the affected side, so option B is incorrect.
張力性氣胸的緊急減壓（Needle thoracostomy）在美國部分州的急診護理師具執行權，但在台灣仍以醫師執行為原則。