— 生理適應 · MEDIUM · MCQ —
護理師正在照護一位肺栓塞（PE）病人。哪項評估發現需要立即向醫師報告？
A nurse is caring for a client with pulmonary embolism (PE). Which assessment finding requires immediate reporting to the physician?
- AOxygen saturation of 94% on supplemental oxygen輔助氧氣下血氧飽和度為 94%
- BHeart rate of 105 bpm心跳速率為 105 次/分
- CClient reporting mild pleuritic chest pain病人主訴輕微胸膜性胸痛
- DSudden decrease in oxygen saturation to 85% and increased dyspnea✓ 正解血氧飽和度突然降至 85% 且呼吸困難加劇
— Explanation · 中文詳解 —
PE 病人若出現血氧飽和度突然顯著下降（如降至 85%）且呼吸困難加劇，可能表示栓塞範圍擴大或出現新的栓塞，導致氣體交換嚴重惡化，需要立即處理。心率 105 bpm、血氧 94% 和輕微胸痛則需監測，但不如血氧驟降緊急。
If a PE client experiences a sudden and significant drop in oxygen saturation (such as to 85%) and worsening dyspnea, this may indicate extension of the embolism or a new embolism, leading to severe deterioration of gas exchange, and requires immediate intervention. A heart rate of 105 bpm, oxygen saturation of 94%, and mild chest pain require monitoring but are not as urgent as the sudden drop in oxygen saturation.
✦ 台美臨床差異
美國的急診室或加護病房有標準化的 PE 處置流程，強調抗凝血與溶栓治療的選擇；台灣在此方面也遵循國際準則，但病人因疼痛或呼吸窘迫而影響配合度的情況需特別注意。