— 照護管理 · HARD · SATA —
護理師照顧數位病人，哪些情況需立即通知醫師？（選所有適合的）
A nurse is caring for several clients. Which findings require immediate notification to the provider? (Select all that apply.)
- AA client with a chest tube showing continuous bubbling in the water seal chamber✓ 正解胸管水封瓶出現持續冒泡的客戶
- BA client on heparin with a PTT value of 120 seconds✓ 正解接受肝素治療且 PTT 值為 120 秒的客戶
- CA client with a new onset of sudden confusion after hip surgery✓ 正解髖關節手術後新發突發性意識混亂的客戶
- DA client with a potassium level of 4.2 mEq/L鉀離子濃度為 4.2 mEq/L 的客戶
- EA client with a blood pressure of 160/95 mmHg who is asymptomatic血壓為 160/95 mmHg 但無症狀的客戶
— Explanation · 中文詳解 —
護理師需具備敏銳的臨床評估能力，識別醫療緊急狀況。A：胸管引流持續冒泡代表氣胸洩漏，需立即處理；B：PTT 120 秒代表凝血功能過度亢進，出血風險極高，需立即通知醫師調整肝素劑量；C：術後突發意識改變可能是脂肪栓塞或譫妄，需立即評估。D（鉀離子 4.2）屬於正常範圍，E（血壓 160/95）若無症狀則屬於慢性控制範疇，無需立即通知醫師。
Continuous bubbling in the water-seal chamber indicates an air leak requiring immediate intervention. A PTT of 120 seconds is critically elevated, placing the client at extreme risk for hemorrhage. New-onset confusion after hip surgery may indicate a fat embolism or neurological compromise.