— 生理適應 · HARD · MCQ —
患者懷疑肺栓塞，護理師應優先評估哪項內容？
A client is admitted with suspected pulmonary embolism. What is the nurse's priority assessment?
- AOxygen saturation and respiratory rate✓ 正解血氧飽和度與呼吸頻率
- BLower extremity swelling下肢腫脹
- CPresence of homans sign霍曼氏徵象 (Homans sign) 的存在
- DCoagulation study results凝血研究結果
— Explanation · 中文詳解 —
肺栓塞（Pulmonary Embolism, PE）會導致肺部血流灌流不足，引發嚴重的換氣灌流失衡（V/Q mismatch），導致缺氧與呼吸窘迫。護理師的優先評估必須遵循 ABC（氣道、呼吸、循環）原則。呼吸頻率與血氧飽和度是偵測病人是否處於呼吸衰竭邊緣的最直接指標，直接影響病人的生命安全，故為優先評估項目。
Pulmonary embolism (PE) results in inadequate perfusion of lung blood flow, producing severe ventilation-perfusion (V/Q) mismatch with hypoxemia and respiratory distress. The nurse's priority assessment must follow the ABC (airway, breathing, circulation) principles. Respiratory rate and oxygen saturation are the most direct indicators of whether the client is on the verge of respiratory failure and directly affect patient safety, making them the priority assessment.