— 降低風險 · HARD · SATA —
護理師照護一位疑似氣胸的病人，應預期出現哪些臨床表徵？（選所有適合的）
A nurse is caring for a client with a suspected pneumothorax. Which clinical findings should the nurse anticipate? (Select all that apply.)
- ADiminished breath sounds on the affected side✓ 正解患側呼吸音減弱
- BTracheal deviation toward the affected side氣管向患側偏移
- CSudden onset of sharp pleuritic chest pain✓ 正解突發性尖銳的胸膜性胸痛
- DHyperresonance on percussion of the affected side✓ 正解患側叩診呈過清音
- ETachycardia and tachypnea✓ 正解心搏過速與呼吸過速
— Explanation · 中文詳解 —
氣胸病人因肺葉塌陷，患側呼吸音減弱或消失；空氣積聚於胸膜腔導致敲診呈現過度回音（hyperresonance）。此外，因呼吸代償機制，病人常出現心跳過速、呼吸急促及突發性胸痛。選項 B 錯誤：氣管偏移通常發生於張力性氣胸時，且方向是「背離」患側而非朝向。
In pneumothorax, the lung collapses on the affected side so breath sounds are diminished or absent and percussion is hyperresonant due to pleural air. Compensatory tachycardia, tachypnea, and sudden pleuritic chest pain are common. Option B is incorrect because tracheal deviation occurs with tension pneumothorax and deviates away from (not toward) the affected side.
✦ 台美臨床差異
美國護理師在胸腔護理中常需負責監控胸管引流瓶（WSD）的波動情況；台灣護理師亦同，但胸管置入後的處置多由專科醫師執行。