一位左腿深部靜脈栓塞（DVT）的病患入院。下列哪項評估發現需要立即通知醫師？
A client is admitted with deep vein thrombosis (DVT) in the left leg. Which assessment finding requires immediate notification to the healthcare provider?
- APainless swelling of the entire left leg整個左腿無痛性腫脹
- BSudden onset of shortness of breath and pleuritic chest pain✓ 正解突發性呼吸困難與肋膜性胸痛
- CEcchymosis at the site of heparin injection肝素注射部位的瘀斑
- DTenderness and warmth behind the left knee左膝後方的壓痛與溫熱感
DVT 病患最嚴重的併發症是血栓脫落並隨血液回流至心臟，進而引發肺栓塞（PE）。臨床思路上，必須警覺任何從「局部症狀」轉變為「全身或呼吸系統症狀」的跡象。突然的呼吸困難、胸痛（深呼吸時加劇）是 PE 的經典徵兆，這直接威脅氧合作用與生命安全，符合 ABC（Airway, Breathing, Circulation）的最高優先級。選項 A 和 D 是 DVT 的典型預期表現，不代表病情急劇惡化；選項 C 是抗凝血治療的常見副作用，除非範圍極大或伴隨大量出血，否則優先級低於呼吸窘迫。護理師必須在第一時間評估呼吸狀態、給予氧氣並通報醫師啟動診斷程序。
The most serious complication of DVT is dislodgement of the thrombus, which travels through the bloodstream to the heart and causes pulmonary embolism (PE). Clinically, the nurse must be alert to any progression from 'local symptoms' to 'systemic or respiratory symptoms.' Sudden dyspnea and pleuritic chest pain (worsening on deep breathing) are classic signs of PE, which directly threatens oxygenation and life and meets the highest ABC (Airway, Breathing, Circulation) priority. Options A and D are typical expected findings of DVT and do not indicate sudden deterioration; option C is a common side effect of anticoagulation, and unless extensive or accompanied by significant bleeding, its priority is lower than that of respiratory distress. The nurse must assess respiratory status immediately, administer oxygen, and notify the physician to initiate diagnostic procedures.
美國護理教育極度強調「Red Flags」的辨識，對於疑似 PE 的處置通常包含護理師直接啟動氧氣治療並同時通報；台灣則常在醫師評估並安排 CT 檢查後才由醫囑決定氧氣流量，自主性略有差異。