一位病人於胸腔穿刺後 2 小時，護理師觀察到病人出現呼吸急促、心跳過速及胸部擴張不對稱。護理師應優先執行何項措施？
A nurse is caring for a client who is 2 hours post-thoracentesis. The nurse notes the client is experiencing tachypnea, tachycardia, and asymmetrical chest expansion. Which action should the nurse take first?
- AObtain an emergency chest X-ray取得緊急胸部 X 光
- BAdminister oxygen via non-rebreather mask✓ 正解透過非再吸入式面罩給予氧氣
- CNotify the healthcare provider通知醫療提供者
- DAuscultate for diminished breath sounds聽診呼吸音減弱的區域
胸腔穿刺後出現呼吸急促與胸部擴張不對稱，高度懷疑醫源性氣胸。根據 ABC 原則，護理師應先給氧以改善缺氧狀態，再進行評估與通知醫師。給氧是維護生命徵象的第一優先步驟，氣胸會影響換氣功能，必須立即緩解低血氧。
Tachypnea and asymmetrical chest expansion 2 hours after thoracentesis are highly suspicious for iatrogenic pneumothorax. According to the ABC principle, the nurse should first administer oxygen to correct hypoxia, then perform further assessment and notify the provider. Administration of oxygen is the first priority to stabilize vital signs, because pneumothorax impairs ventilation and hypoxia must be addressed immediately.
美國護理師常有授權可直接給氧；台灣護理師亦可給氧，但若需提升至高濃度氧氣或特定裝置，通常需醫師緊急醫囑。