心導管治療 (PCI) 後，病人的股動脈處留有止血鞘管。哪項評估發現需要立即處理？
The nurse is caring for a client with a femoral arterial sheath after percutaneous coronary intervention (PCI). Which assessment finding requires immediate intervention?
- ABack pain and a 20 mmHg drop in systolic blood pressure✓ 正解背痛及收縮壓下降 20 mmHg
- BSlight bruising at the insertion site插入部位有輕微瘀青
- CClient reporting being tired and wanting to sleep病人表示感到疲倦並想睡覺
- DStrong pedal pulses on the affected limb患肢足背動脈搏動強
股動脈穿刺後，病人的背痛（或腰痛）伴隨血壓下降，是發生後腹腔出血（Retroperitoneal hemorrhage）的典型隱性徵候。由於出血發生在腹膜後，外部傷口可能看不到大量出血。這是 PCI 術後致死率極高的併發症，必須立即通知醫師並準備急救。A 為正常；C 為預期；D 亦屬常見。
After femoral artery puncture, back or flank pain accompanied by a drop in blood pressure is a classic occult sign of retroperitoneal hemorrhage. Because the bleeding occurs behind the peritoneum, no external bleeding may be visible. This is a complication of PCI with high mortality, and the physician must be notified immediately while preparing for emergency intervention. Option D is normal, option B is expected, and option C is also common.
美國 NCLEX 極重視 Retroperitoneal hemorrhage 的識別；台灣臨床實務中，護理師需警覺不明原因腰痠與心率增快。