護理師照護一名全髖關節置換術後 24 小時的病人。病人突然出現劇烈胸痛和呼吸困難。護理師應優先採取哪項措施？
A nurse is caring for a client who is 24 hours postoperative following a total hip arthroplasty. The client suddenly develops sharp chest pain and dyspnea. Which intervention should the nurse prioritize?
- AApply supplemental oxygen via nasal cannula經鼻導管給予補充氧氣正確答案
- BEncourage the client to use the incentive spirometer鼓勵病人使用誘發性肺量計
- CObtain a lower extremity venous Doppler ultrasound進行下肢靜脈都卜勒超音波檢查
- DAdminister the prescribed PRN morphine for pain給予處方之需要時使用（PRN）嗎啡以止痛
- A經鼻導管給予補充氧氣
此臨床場景高度懷疑為肺栓塞（Pulmonary Embolism, PE）。全髖關節置換術是深部靜脈栓塞（DVT）的高風險因子，當血栓脫落進入肺循環時，會導致急性缺氧和胸痛。根據 ABC（Airway-Breathing-Circulation）優先原則，病人在出現呼吸困難與急性胸痛時，首要任務是確保氧合（Breathing）。給予氧氣（A）能立即減緩組織缺氧，並改善病人的自覺症狀。止痛藥（D）雖能緩解胸痛，但無法解決底層的缺氧問題；誘發性肺量計（B）主要用於預防術後肺塌陷，對已發生的 PE 無效；超音波檢查（C）是後續的診斷步驟，不能先於生命徵象的穩定。護理師必須敏銳察覺『術後、突然、胸痛、呼吸困難』這四個關鍵詞組成的 PE 警訊。
- A · 正確答案經鼻導管給予補充氧氣
給予氧氣是針對疑似肺栓塞導致缺氧的第一線處理，符合急救優先順位，能緩解呼吸困難。
- B鼓勵病人使用誘發性肺量計
誘發性肺量計用於預防術後併發症，但在病人急性缺氧且疼痛的當下，並無治療 PE 的效果。
- C進行下肢靜脈都卜勒超音波檢查
血管超音波是確認有無 DVT 的檢查，但在懷疑 PE 的緊急狀況下，穩定病人呼吸狀態才是首要工作。
- D給予處方之需要時使用（PRN）嗎啡以止痛
嗎啡雖然能止痛，但會抑制呼吸驅動力，且無法解決栓塞導致的氣體交換障礙，並非首選。
美國護理教育極度強調護理師對於 PE 警訊的『早期識別』與『立即供氧』，不需等待醫囑即可啟動基本氧療；台灣臨床環境中，護理師通常會同步通知醫師與準備氧氣，但對於獨立判斷與執行 PE 處置的強調程度略遜於美國考題。
English explanation
This clinical scenario raises high suspicion for pulmonary embolism (PE). Total hip arthroplasty is a high-risk factor for deep vein thrombosis (DVT); when a thrombus dislodges into the pulmonary circulation, it produces acute hypoxia and chest pain. According to the ABC (airway-breathing-circulation) priority principle, when the client develops dyspnea and acute chest pain, the first priority is to ensure oxygenation (breathing). Administering oxygen (option A) immediately alleviates tissue hypoxia and improves the client's subjective symptoms. Analgesics (option D) may relieve chest pain but cannot address the underlying hypoxia; the incentive spirometer (option B) is primarily for prevention of postoperative atelectasis and is ineffective for an already established PE; ultrasound (option C) is a subsequent diagnostic step and should not precede stabilization of vital signs. The nurse must be alert to the PE warning signs formed by the four key phrases "postoperative, sudden, chest pain, and dyspnea."
最近修訂：2026-10-06