一位接受全髖關節置換術後兩天的病人，哪些發現應提示護理師可能出現肺栓塞？（選所有適合的）
A nurse is caring for a client who is two days postoperative following a total hip arthroplasty. Which findings should the nurse identify as indicators of possible pulmonary embolism? (Select all that apply.)
- ASudden onset of dyspnea✓ 正解突發性呼吸困難
- BTachycardia and tachypnea✓ 正解心跳過速與呼吸過速
- CPleuritic chest pain✓ 正解胸膜炎性胸痛
- DProductive cough with rust-colored sputum咳出鐵鏽色痰的產痰性咳嗽
- EApprehension and feeling of impending doom✓ 正解焦慮與瀕死感
全髖關節置換術後病人因長期臥床及手術創傷，處於深層靜脈血栓（DVT）的高風險群，血栓脫落極易引發肺栓塞（PE）。肺栓塞的臨床表現取決於栓塞大小，最典型徵象包括突發性呼吸困難、心跳過快與呼吸急促（為了補償通氣血流比失調），以及胸膜炎性胸痛（吸氣時加劇）。病人常主訴無法解釋的焦慮感，即所謂的『瀕死感』（impending doom），這是缺氧與交感神經刺激的心理反應。rust-colored sputum 則是典型肺炎的產物，而非肺栓塞。護理師在觀察到此組合症狀時，應立即採取高流量氧氣給予，並呼叫醫療團隊以啟動緊急評估流程。這種情況下，氧氣治療與血液動力學監測是護理焦點。
Clients who have undergone total hip arthroplasty are at high risk for deep vein thrombosis (DVT) due to prolonged bed rest and surgical trauma, and a dislodged thrombus can readily produce pulmonary embolism (PE). The clinical presentation of PE depends on the size of the embolus; classic findings include sudden onset of dyspnea, tachycardia and tachypnea (to compensate for the ventilation-perfusion mismatch), and pleuritic chest pain (worse on inspiration). Clients often report unexplained anxiety or a so-called sense of impending doom, which is the psychological reflex of hypoxia and sympathetic stimulation. Rust-colored sputum is typical of pneumonia, not pulmonary embolism. When the nurse observes this combination of symptoms, high-flow oxygen should be administered immediately, and the medical team should be called to initiate an emergency evaluation pathway. In this situation, oxygen therapy and hemodynamic monitoring are the focus of nursing care.
美國護理機構極度重視術後深層靜脈血栓的預防教育，包括鼓勵早期下床與使用間歇性氣壓設備（IPC）；台灣在骨科手術後的下床活動參與度較保守，護理師對於潛在 PE 的預警評估訓練多以學理為主，臨床實務中較依賴醫師判斷。