護理師照護一位肺栓塞 (PE) 病人。哪項評估發現需要立即介入？
A nurse is caring for a client with a pulmonary embolism (PE). Which assessment finding requires immediate intervention?
- AHemoptysis咳血
- BD-dimer elevatedD-dimer 升高
- CChest pain胸痛
- DSudden drop in SpO2 and increased heart rate✓ 正解SpO2 突然下降且心率增加
肺栓塞（Pulmonary Embolism, PE）的核心病理在於血栓阻塞肺動脈，導致肺部通氣/灌流（V/Q）失調，進而引發低血氧與血流動力學不穩定。當病人出現 SpO2 驟降伴隨心跳加速，這是典型的代償機制失效表現，預示著可能進入阻塞性休克或急性呼吸衰竭，屬於高優先級（Priority）的臨床惡化指標。護理師必須依據 ABC（Airway, Breathing, Circulation）原則，優先處理呼吸與循環危機，而非僅僅監測數據。
The core pathology of pulmonary embolism (PE) is occlusion of the pulmonary artery by a thrombus, which causes ventilation/perfusion (V/Q) mismatch and results in hypoxemia and hemodynamic instability. When a client develops a sudden drop in SpO2 accompanied by tachycardia, this represents the failure of compensatory mechanisms and signals possible progression to obstructive shock or acute respiratory failure, making it a high-priority indicator of clinical deterioration. According to the ABC principle (Airway, Breathing, Circulation), the nurse must prioritize management of respiratory and circulatory crises rather than merely monitoring the data.