一位患有急性呼吸窘迫症候群 (ARDS) 且正在接受插管的病人，呼吸器壓力警報響起。護理師首要採取哪項行動？
A client is diagnosed with acute respiratory distress syndrome (ARDS) and is currently intubated. The peak airway pressure alarm is sounding. What is the nurse's first action?
- AIncrease the fraction of inspired oxygen (FiO2)增加吸入氧氣濃度 (FiO2)
- BAuscultate lung sounds✓ 正解聽診肺部呼吸音
- CSuction the endotracheal tube對氣管內管進行抽吸
- DManually ventilate with a resuscitation bag使用復甦球手動通氣
當呼吸器發出高壓力警報時，應先排除呼吸道阻塞、氣胸或肺部順應性變化。聽診肺部聲音是評估氣道是否通暢及管路位置是否正確的首要步驟，若聽診後發現異常再執行抽痰或手動換氣。過早抽痰可能不必要，而手動換氣是若排除管路異常後的應變措施。
When the ventilator triggers a high peak airway pressure alarm, the nurse should first rule out airway obstruction, pneumothorax, or changes in lung compliance. Auscultating breath sounds is the first step to evaluate airway patency and confirm proper tube placement; suctioning or manual ventilation should be performed only if auscultation reveals abnormalities. Premature suctioning may be unnecessary, and manual ventilation is the response measure used only after a mechanical problem with the airway is excluded.
美國護理師常直接調整呼吸器設定，台灣呼吸治療師（RT）角色明確，護理師需與 RT 密切配合評估管路。