— 生理適應 · MEDIUM · MCQ —
一位診斷為急性呼吸窘迫症候群（ARDS）的病人，護理師應優先監測哪項指標以防範潛在併發症？
A client is diagnosed with acute respiratory distress syndrome (ARDS). What is the priority nursing assessment to monitor for potential complications?
- AUrine output尿量
- BOxygen saturation level✓ 正解血氧飽和度
- CLevel of consciousness意識狀態
- DSerum potassium level血清鉀離子濃度
— Explanation · 中文詳解 —
ARDS 的主要病理機轉為瀰漫性肺泡損害，導致嚴重的低血氧。護理師需優先透過脈衝式血氧儀監測氧氣飽和度，評估肺部氣體交換功能是否惡化，這是病人生命安全最直接的威脅，需即時反應以調整呼吸器參數或氧氣濃度。
The principal pathophysiologic mechanism of ARDS is diffuse alveolar damage, leading to severe hypoxemia. The nurse must prioritize monitoring oxygen saturation with pulse oximetry to evaluate whether pulmonary gas exchange is deteriorating; this is the most direct threat to the client's life and requires immediate response to adjust ventilator settings or oxygen concentration.
✦ 台美臨床差異
美國重症護理師多依據 Protocol 調整 PEEP；台灣則高度依賴醫師開立設定值。