護理師評估疑似氣胸的病人，應優先注意哪項臨床徵象？
A nurse is assessing a client with a suspected pneumothorax. Which clinical manifestation should the nurse prioritize?
- AAbsent breath sounds on the affected side✓ 正解患側呼吸音消失
- BSubcutaneous emphysema皮下氣腫
- CHyper-resonance on percussion叩診呈過清音
- DTracheal deviation toward the affected side氣管向患側偏移
氣胸造成肺部塌陷，最直接的徵象是患側呼吸音消失。氣管偏移（D）若朝向對側則暗示張力性氣胸，屬危急狀態，但呼吸音消失是辨識肺部通氣異常的最基本且優先指標。叩診過度清音（C）與皮下氣腫（B）雖為氣胸表徵，但不及呼吸音消失更能直接反映換氣失敗。
Pneumothorax causes lung collapse, and the most direct sign is absent breath sounds on the affected side. Tracheal deviation (D), if shifted toward the opposite side, suggests tension pneumothorax—a critical state—but absent breath sounds remain the most fundamental and prioritized indicator for identifying abnormal pulmonary ventilation. Hyperresonance on percussion (C) and subcutaneous emphysema (B) are also manifestations of pneumothorax, but they do not reflect ventilation failure as directly as absent breath sounds.
美台護理教育均強調聽診的重要性，但美國護理師在重症單位執行肺部評估的獨立性與準確度要求極高。