— 降低風險 · EASY · MCQ —
護理師照護一位剛完成股動脈心導管檢查返回病房的病人。下列哪項措施為優先執行事項？
A nurse is caring for a client who has just returned to the unit following a cardiac catheterization via the femoral artery. Which action is the priority for the nurse to perform?
- AEncourage the client to increase fluid intake鼓勵個案增加液體攝取
- BCheck distal pulses in the affected extremity✓ 正解檢查患肢遠端的脈搏
- CAssess the puncture site for bleeding or hematoma評估穿刺部位是否有出血或血腫
- DAssess the client's pain level評估個案的疼痛程度
— Explanation · 中文詳解 —
心導管術後發生血管併發症的風險最高。評估患側遠端脈搏（足背脈搏）是檢測是否有周邊血管栓塞或阻塞的首要指標，確保血液循環通暢。出血評估雖重要，但檢查血流灌流情況對於防止組織缺血壞死具備更高的急迫性與優先級。
The risk of vascular complications is highest after a cardiac catheterization. Assessing the distal pulses of the affected extremity (such as the dorsalis pedis pulse) is the primary indicator for detecting peripheral vascular obstruction or thrombosis and ensures adequate circulation. Assessing for bleeding is also important, but checking perfusion is more urgent and a higher priority for preventing tissue ischemia and necrosis.
✦ 台美臨床差異
美台臨床對於術後評估流程一致，皆重視遠端脈搏強度與皮膚溫度對比。