護理師正在評估一位有心房顫動病史且出現呼吸短促的病人。哪項評估發現最令人擔憂？
A nurse is assessing a client with a history of atrial fibrillation who is experiencing shortness of breath. Which assessment finding is most concerning?
- AOxygen saturation of 92% on room air在室溫空氣下氧飽和度為 92%
- BPresence of bilateral crackles in the lung bases✓ 正解肺底部出現雙側囉音
- CClient reports mild ankle swelling客戶報告腳踝輕微腫脹
- DIrregularly irregular pulse rate of 95 bpm脈搏速率不規則且不整，為 95 bpm
心房顫動可能導致心房收縮效率降低，造成血栓形成或心輸出量下降。若出現雙側肺底囉音，表示有肺水腫，可能是左心衰竭的徵兆，這會導致嚴重的呼吸窘迫。心率 95 bpm 雖不規則，但未達急迫；踝部水腫和 SpO2 92% 需關注但相對不緊急。
Atrial fibrillation can reduce the effectiveness of atrial contraction, leading to thrombus formation or a decrease in cardiac output. Bilateral basilar crackles indicate pulmonary edema and may be a sign of left-sided heart failure, which can cause severe respiratory distress. A heart rate of 95 bpm, although irregular, is not urgent; ankle edema and an SpO2 of 92% warrant attention but are comparatively less critical.
美國心臟科醫師較常使用藥物控制心房顫動的心室率與節律，護理師在照護上會更側重監測藥效與副作用；台灣兩者皆有，但臨床上對新式抗凝血劑的使用與衛教較為強調。