病人診斷為急性呼吸窘迫症候群（ARDS）且已插管，呼吸器發出高氣道壓力警報。護理師應優先採取何種措施？
A client is diagnosed with acute respiratory distress syndrome (ARDS) and is currently intubated. The peak airway pressure alarm sounds. Which action should the nurse take first?
- ASuction the client's airway為病人氣道吸痰
- BSedate the patient more deeply加深病人鎮靜程度
- CAuscultate bilateral breath sounds✓ 正解聽診雙側呼吸音
- DIncrease the tidal volume增加潮氣容積
高氣道壓力警報通常代表氣道阻力增加，原因可能是分泌物積聚、管路扭曲、氣胸或支氣管痙攣。優先評估肺部聽診可快速判斷是否為氣胸或單側阻塞，以便採取對應處理。吸痰雖是常見應對，但未確認原因前盲目吸痰可能加劇缺氧。增加潮氣容積會惡化壓力問題，深鎮靜則未能解決物理阻塞。
A high airway pressure alarm usually indicates increased airway resistance, which may be due to accumulated secretions, kinked tubing, pneumothorax, or bronchospasm. The priority assessment is auscultation of the lungs, which can quickly determine whether pneumothorax or unilateral obstruction is present, allowing appropriate intervention. Although suctioning is a common response, performing it before identifying the cause may worsen hypoxia. Increasing tidal volume would exacerbate the pressure problem, and deep sedation does not address the underlying physical obstruction.
美國重症護理中護理師對於呼吸器報警處置的自主權較大，台灣醫療院所多要求先請呼吸治療師評估。