一位 C4 頸脊髓損傷病人，下列哪項發現需要最立即的介入？
Which assessment finding in a client with a cervical spinal cord injury at the C4 level requires the most immediate intervention?
- AAbsence of bowel sounds腸鳴音消失
- BBlood pressure of 90/60 mmHg血壓 90/60 mmHg
- COxygen saturation of 89% on room air✓ 正解室空氣下氧飽和度 89%
- DPulse rate of 55 beats per minute脈搏 55 次/分
C4 損傷會影響橫膈膜神經，導致呼吸功能受損。SpO2 89% 代表缺氧，直接威脅生命安全，需立即給予氧氣支持或評估插管需求。雖然心跳過緩與低血壓也常見於脊髓休克，但 ABC 原則中呼吸（Airway/Breathing）永遠是第一優先。低血氧會迅速導致器官衰竭與心跳停止，因此處置應以改善通氣為先。
A C4 injury affects the phrenic nerve, leading to impaired respiratory function. An SpO2 of 89% indicates hypoxia, which is a direct threat to life and requires immediate oxygen support or evaluation for intubation. Although bradycardia and hypotension are also common with spinal shock, the ABC principle places airway/breathing above all else. Hypoxia can rapidly lead to organ failure and cardiac arrest, so management must prioritize improving ventilation.
美台皆將氣道評估置於首位，美國護理師在重症單位有更多權限啟動呼吸治療評估。