— 生理適應 · HARD · MCQ —
病人入院懷疑有肺栓塞，護理師應優先評估下列哪項？
A client is admitted with a suspected pulmonary embolism. Which priority assessment should the nurse perform?
- AAssess respiratory rate and SpO2✓ 正解評估呼吸頻率與血氧飽和度（SpO2）
- BCheck for peripheral pulses檢查周邊脈搏
- CCheck for calf pain and swelling檢查小腿疼痛與腫脹
- DAuscultate bowel sounds聽診腸鳴音
— Explanation · 中文詳解 —
肺栓塞（PE）直接影響氣體交換，導致缺氧，危及生命。呼吸速率與血氧飽和度是評估呼吸衰竭的核心指標。A（小腿腫痛）雖是 PE 的前驅因素（DVT），但已出現 PE 症狀時，呼吸狀態的緊急性遠高於肢體評估。B、D 與 PE 無關。
Pulmonary embolism (PE) directly impairs gas exchange, leading to hypoxemia and threatening life. Respiratory rate and oxygen saturation are the core indicators used to assess respiratory failure. Although calf pain and swelling (C) reflect the precursor lesion (DVT) of PE, once PE symptoms are present the urgency of respiratory assessment far outweighs limb assessment. Options B and D are unrelated to PE.
✦ 台美臨床差異
美國護理師常依 PE 臨床預測評分表（如 Wells score）協助醫生評估，台灣則由醫師決定檢查項目。