護理師照護一位經由股動脈進行心導管檢查後剛返回單位的病人。哪項措施是最高優先級？
A nurse is caring for a client who has just returned to the unit following a cardiac catheterization via the femoral artery. Which action is the highest priority?
- AMonitor blood pressure every 15 minutes每 15 分鐘監測血壓
- BCheck the pedal pulses distal to the site✓ 正解檢查穿刺點遠端的足背動脈搏動
- CEncourage increased oral fluid intake鼓勵增加口服液體攝取
- DAssess the puncture site for hematoma評估穿刺部位是否有血腫
心導管檢查後，血管穿刺部位的遠端血液循環評估是確保組織灌流的核心指標。股動脈（femoral artery）穿刺後，最嚴重的急症為動脈閉塞或嚴重出血導致的肢體缺血。根據 ABC 原則（循環），護理師需優先確認該側肢體遠端脈搏（pedal pulses）、皮膚顏色、溫度及毛細血管充盈時間，以早期發現血栓形成的跡象。
After cardiac catheterization, assessment of distal circulation at the puncture site is the key indicator of tissue perfusion. Following femoral artery puncture, the most serious acute complications are arterial occlusion or severe bleeding leading to limb ischemia. Following the ABC principle (circulation), the nurse must first verify distal pulses (pedal pulses), skin color and temperature, and capillary refill time on the affected limb to detect signs of thrombus formation early.
在美國臨床，心導管術後病人的評估流程非常標準化（Neurovascular checks），護理師需嚴格執行「Pulse check, Color, Temperature, Capillary refill」，且對於穿刺部位的監測紀錄非常詳細，甚至包含壓迫裝置（如 TR Band 或 Femostop）的壓力調整。