護理師照護一位剛完成心導管檢查返回病房的病人。下列哪項評估發現需要立即處理？
A nurse is caring for a client who has just returned to the unit following a cardiac catheterization. Which assessment finding requires immediate intervention?
- AAbsence of a pulse distal to the insertion site✓ 正解插入部位遠端脈搏消失
- BPalpable pulses in the affected extremity患肢可觸及脈搏
- CA small amount of serosanguineous drainage on the dressing敷料上有少量漿血性滲出液
- DModerate discomfort at the insertion site插入部位有中度不適
心導管術後發生動脈栓塞或出血是嚴重併發症。若穿刺處遠端脈搏消失，暗示血液灌流受阻，可能導致肢體缺血壞死。護理師須立即評估肢體顏色與溫度，並通知醫師處理。其他選項如少量滲液或輕微不適屬預期內反應，重點應擺在血管通暢度與出血監控。
Arterial embolism or hemorrhage following cardiac catheterization is a serious complication. If pulses distal to the puncture site disappear, it suggests impaired blood flow that may cause limb ischemia and necrosis. The nurse must immediately assess limb color and temperature and notify the physician. The other findings, such as small amounts of drainage or mild discomfort, are expected; the focus must be on vascular patency and hemorrhage monitoring.
美台臨床皆視脈搏消失為緊急事件，惟台灣單位主管可能要求更頻繁的血管監測頻率紀錄。