— 基本照護與舒適 · MEDIUM · MCQ —
一位病人在平躺時出現呼吸困難。護理師應採取何種措施？
A client is experiencing dyspnea while lying flat. What is the best nursing intervention?
- AAdminister an inhaler immediately立即給予吸入劑
- BInstruct the client to breathe in and out quickly指示病人快速呼吸
- CPerform a physical assessment of the abdomen進行腹部理學評估
- DPlace the client in a high-Fowler's position✓ 正解將病人置於高福勒氏臥位
— Explanation · 中文詳解 —
端坐呼吸（Orthopnea）時應採取高坐姿（High-Fowler's），利用重力降低橫膈膜壓力，改善肺部擴張。使用吸入器（A）需醫師處方且須評估適應症；快呼吸（B）會導致過度換氣；評估腹部（C）雖可進行但優先順序次於緩解呼吸窘迫。
For orthopnea, the client should be placed in a high-Fowler's position to use gravity to reduce pressure on the diaphragm and improve lung expansion. Administering an inhaler (A) requires a provider's order and must be evaluated for indication; rapid breathing (B) leads to hyperventilation; abdominal assessment (C), although possible, takes lower priority than relieving respiratory distress.
✦ 台美臨床差異
美國護理師常依據病人的呼吸狀態直接調整姿勢，台灣亦同，但需在病歷註記變更原因。