一位左腿患有深層靜脈栓塞 (DVT) 的病人，護理師應將哪項評估結果視為應立即介入的優先事項？
A client is diagnosed with a deep vein thrombosis (DVT) in the left leg. Which assessment finding should the nurse identify as the priority for immediate intervention?
- AIncrease in calf circumference of 1 cm小腿周徑增加 1 cm
- BPitting edema in the affected leg患側腿部凹陷性水腫
- CSudden onset of shortness of breath and chest pain✓ 正解突然出現呼吸困難和胸痛
- DLocalized warmth and tenderness in the affected leg患側腿部局部溫熱和壓痛
DVT 病人最大的潛在生命威脅是血栓脫落並隨血液回流至肺部，造成肺栓塞（PE）。突發性的呼吸短促（Shortness of Breath）與胸痛是肺栓塞的典型「紅旗」症狀，必須立即介入（給氧、通知醫師、準備抗凝治療）。其他選項（如小腿圍增加、水腫、局部壓痛）雖然是 DVT 的預期臨床表現，但不具備立即致命的風險。護理師在處理 DVT 時，思維必須從「局部症狀監測」轉向「全身性併發症預防」。ABC 原則（Airway, Breathing, Circulation）在此題中引導我們選擇 B，因為它直接威脅呼吸功能。
The greatest life-threat for a DVT client is clot dislodgement traveling through the venous circulation to the lungs, causing pulmonary embolism (PE). Sudden shortness of breath and chest pain are classic red-flag symptoms of PE and require immediate intervention (oxygen, notify provider, prepare anticoagulation). The other options (increased calf circumference, edema, local tenderness) are expected DVT findings but are not immediately life-threatening. ABC priorities lead to B because it directly threatens respiratory function.
在美國護理教育中，DVT 轉 PE 的演變是「必須知道」（Must-know）的急症。美國護理師常被授權在懷疑 PE 時立即啟動 Rapid Response Team (RRT)。台灣則強調立即通報值班醫師，並在等待醫師到達前先給予 2-4L 鼻導管氧氣，兩地對於「PE 是 DVT 的首要致死原因」之共識完全一致。