一位病人突然出現疑似肺栓塞的症狀，護理師應優先執行哪項評估？
A nurse is caring for a client who develops a sudden onset of symptoms suggestive of a pulmonary embolism. Which priority assessment should the nurse perform?
- AAssess the client for pedal edema評估個案是否有足部水腫
- BObtain a full set of vital signs including SpO2✓ 正解測量包含血氧飽和度在內的全套生命徵象
- CPalpate the calf for tenderness觸診小腿是否有壓痛
- DAuscultate for lung sounds聽診肺部呼吸音
肺栓塞屬於生命威脅，優先評估呼吸穩定性與循環狀態。生命徵象（包含脈搏、血壓、氧氣飽和度）是判斷呼吸衰竭或休克的關鍵。雖然下肢評估有助診斷深部靜脈栓塞，但在生命徵象不穩定時，必須先確認 ABC 的受損程度。
Pulmonary embolism is a life-threatening event, and respiratory stability and circulatory status must be assessed first. Vital signs (including pulse, blood pressure, and oxygen saturation) are key to identifying respiratory failure or shock. Although lower extremity assessment can aid in diagnosing deep vein thrombosis, when vital signs are unstable the nurse must first determine the degree of compromise to the ABCs (airway, breathing, circulation).
美台護理師皆接受過啟動緊急醫療團隊 (Rapid Response Team) 的訓練，緊急評估邏輯一致。