— 生理適應 · MEDIUM · MCQ —
一位嚴重肺炎病人入院。護理師評估其呼吸狀態。哪項發現提示氣體交換受損？
A client with severe pneumonia is admitted to the hospital. The nurse assesses the client's respiratory status. Which finding indicates impaired gas exchange?
- ARespiratory rate 24 breaths/min呼吸速率 24 次/分
- BCough with yellow sputum咳出黃色痰液
- CSpO2 88% on room air✓ 正解在室溫空氣下 SpO2 88%
- DUse of accessory muscles使用輔助呼吸肌
— Explanation · 中文詳解 —
血氧飽和度 (SpO2) 88% 表示組織缺氧，是氣體交換受損的直接指標。肺炎時，肺泡內的液體或滲出物會阻礙氧氣進入血液。呼吸過快、使用輔助肌和咳嗽是身體的代償反應，但 SpO2 低是氣體交換失敗的關鍵證據。
An oxygen saturation (SpO2) of 88 percent indicates tissue hypoxia and is a direct indicator of impaired gas exchange. In pneumonia, alveolar fluid or exudate obstructs the entry of oxygen into the bloodstream. Tachypnea, use of accessory muscles, and coughing are the body's compensatory responses, but a low SpO2 is the key evidence of failed gas exchange.
✦ 台美臨床差異
美國重症照護護理師使用連續心肺監測儀器評估氣體交換；台灣則依賴間歇性監測和臨床觀察，但血氧計普及度高。