護理師照護一位剛經由股動脈接受心導管檢查的病人。下列哪項措施為最高優先？
A nurse is caring for a client who has just undergone a cardiac catheterization via the femoral artery. Which action is the highest priority?
- AMonitor the insertion site for bleeding or hematoma監測插入部位是否有出血或血腫
- BCheck distal pulses in the affected extremity✓ 正解檢查患肢遠端動脈搏動
- CEncourage fluid intake to promote dye excretion鼓勵攝取液體以促進染料排泄
- DMaintain the client on strict bed rest as ordered遵照醫囑讓客戶嚴格卧床休息
心導管檢查後，評估末梢循環（如足背動脈脈搏）是確保沒有因血栓或血腫壓迫導致血管阻塞的關鍵。雖然止血與限制活動很重要，但若末梢脈搏消失，代表發生嚴重併發症，會導致組織缺血壞死，因此評估末梢脈搏優先於水分攝取或活動限制。
After cardiac catheterization, assessing peripheral circulation (such as dorsalis pedis pulses) is key to ensuring that no vascular obstruction from thrombus or hematoma compression has occurred. Although hemostasis and activity restriction are important, the disappearance of a distal pulse indicates a serious complication that can lead to ischemic tissue necrosis. Therefore, assessment of distal pulses takes priority over fluid intake or activity restriction.
美國醫院對於心導管後的血管鞘（Sheath）拔除護理有嚴格的專科護理規範，台灣則較多由醫師親自處理或由資深專科護理師執行。