— 生理適應 · HARD · MCQ —
針對疑似張力性氣胸的病人，下列哪項評估結果需要護理師採取最緊急的措施？
Which assessment finding in a client with a suspected tension pneumothorax warrants the most urgent action by the nurse?
- ASubcutaneous emphysema皮下氣腫
- BPleuritic chest pain胸膜炎性胸痛
- CTracheal deviation to the unaffected side✓ 正解氣管向未受影響側偏移
- DDiminished breath sounds on the affected side患側呼吸音減弱
— Explanation · 中文詳解 —
張力性氣胸屬於危急生命狀況，因為氣體進入胸膜腔無法排出，壓力堆積造成縱隔腔偏移並壓迫對側肺部與心臟血管，導致心輸出量下降。氣管偏移（Tracheal deviation）是縱隔腔受壓迫的晚期且危險徵象，代表心肺功能即將衰竭。
Tension pneumothorax is a life-threatening condition: air entering the pleural space cannot escape, and pressure builds up, causing mediastinal shift and compression of the contralateral lung and great vessels, with resulting decrease in cardiac output. Tracheal deviation is a late and dangerous sign of mediastinal compression, indicating impending cardiopulmonary collapse.
✦ 台美臨床差異
在美國，這類情況護理師應直接啟動快速反應小組；台灣多是優先通知值班醫師進行針刺減壓。