— 降低風險 · HARD · MCQ —
護理師照護一位剛執行中心靜脈導管（CVC）放置術的病人，病人突然出現躁動、呼吸困難及心搏過速。下列何者為優先措施？
A nurse is caring for a client who develops a sudden onset of agitation, dyspnea, and tachycardia following a central line insertion. Which action is the priority?
- AAdminister oxygen via a non-rebreather mask透過非再吸入式面罩給予氧氣
- BPlace the client in Trendelenburg position on the left side✓ 正解將病人置於左側 Trendelenburg 體位
- CNotify the provider immediately立即通知醫師
- DObtain an emergent chest X-ray安排緊急胸部 X 光檢查
— Explanation · 中文詳解 —
上述症狀高度懷疑為氣體栓塞（Air Embolism）。護理師應立即將病人擺放於左側臥位（Left lateral decubitus），並採取頭低腳高位（Trendelenburg），目的是將空氣截留在右心室尖端，避免進入肺動脈引發更嚴重的肺栓塞。這是最能改變預後的物理搶救措施。
The above symptoms are highly suspicious for an air embolism. The nurse should immediately place the client in a left lateral decubitus position with Trendelenburg, with the goal of trapping air at the apex of the right ventricle, preventing it from entering the pulmonary artery and causing more severe pulmonary embolism. This is the physical rescue measure most able to change the outcome.
✦ 台美臨床差異
兩地皆強調氣體栓塞的緊急處理，但美國教育體系對於護理師主動採取體位改變的訓練更為強勢。