— 生理適應 · MEDIUM · MCQ —
護理師照護的一位病人出現突發性銳利胸痛與呼吸困難，且有深部靜脈栓塞病史。護理師應優先採取何種行動？
A nurse is caring for a client who develops sudden, sharp chest pain and dyspnea. The client has a history of deep vein thrombosis. Which action is the priority?
- ACheck the client's vital signs檢查病人的生命徵象
- BElevate the head of the bed to a high-Fowler's position✓ 正解將床頭抬高至高福勒氏體位（High-Fowler's position）
- CAdminister pain medication as ordered依指示給予止痛藥物
- DPerform a physical assessment of the lower extremities對下肢進行身體評估
— Explanation · 中文詳解 —
病人的症狀高度懷疑為肺栓塞。優先處置是維持呼吸道通暢與氧氣交換，採取高半坐臥位可減少呼吸肌負荷並改善肺部擴張。其餘檢查生命徵象與評估下肢雖重要，但必須先在呼吸穩定病人後再執行，以免延誤對急性缺氧的處置。
Symptoms strongly suggest pulmonary embolism. Priority is airway/oxygenation — high-Fowler's position reduces respiratory workload and improves lung expansion. Vital signs and lower extremity assessment are important but must follow respiratory stabilization to avoid delaying treatment of acute hypoxia.
✦ 台美臨床差異
美台臨床皆視肺栓塞為急診紅旗，但美國護理師常需更主動介入呼吸支持，而台灣護理師通常會同步呼叫急救小組（Code Blue/Medical Team）。