護理師監測髖關節置換術後 2 天的病人。哪項發現最令護理師擔心發生肺栓塞 (PE)？
The nurse is monitoring a client who had a total hip replacement 2 days ago. Which finding is most concerning for a pulmonary embolism (PE)?
- ASudden onset of shortness of breath and chest pain✓ 正解突發性呼吸困難及胸痛
- BOral temperature of 100.2°F (37.9°C)口腔溫度 100.2°F (37.9°C)
- CPain at the surgical site手術部位疼痛
- DRedness and warmth in the calf小腿紅腫及溫熱
髖關節置換術 (Total hip replacement) 是一種大手術，術後病人因活動受限、臥床時間長，血液循環變慢，導致深部靜脈栓塞 (Deep Vein Thrombosis, DVT) 的風險顯著增加。DVT 的血栓若脫落，可能隨血液循環到達肺部，造成肺栓塞 (Pulmonary Embolism, PE)，這是一種危及生命的急症。 護理師在術後監測病人時，必須高度警惕 PE 的潛在發生，並能迅速識別其臨床表現。突然發生的呼吸短促 (shortness of breath) 和胸痛 (chest pain) 是肺栓塞最典型且最危急的症狀，這些症狀通常提示肺部血管被血栓阻塞，導致氣體交換受損和心肺功能異常。這符合臨床思路中的 ABC (Airway, Breathing, Circulation) 原則，呼吸問題和胸痛直接威脅病人的生命，因此是護理師最應優先關注並立即處理的發現。 其他選項的發現雖然也需關注，但其危急程度遠不及 PE 的典型症狀。
Total hip replacement is a major surgery; postoperative immobility and prolonged bed rest significantly increase the risk of deep vein thrombosis (DVT). If a DVT dislodges, it can travel to the pulmonary circulation and cause a pulmonary embolism (PE), a life-threatening emergency. The nurse must remain vigilant for PE and recognize its presentation quickly. Sudden onset of shortness of breath and chest pain are the most typical and critical PE symptoms, reflecting obstruction of pulmonary vasculature and impaired gas exchange. Following ABC priorities, these respiratory and chest symptoms directly threaten life and demand immediate action. Other findings warrant attention but are not as acutely critical as PE.