— 生理適應 · MEDIUM · MCQ —
一位急性呼吸窘迫症候群（ARDS）個案正使用呼吸器，高壓警報響起。護理師應優先評估什麼？
A client is diagnosed with acute respiratory distress syndrome (ARDS) and is being mechanically ventilated. The high-pressure alarm sounds. What should the nurse assess first?
- APatient-ventilator dyssynchrony病人與呼吸器的同步性
- BPresence of secretions in the airway✓ 正解氣道內是否有分泌物
- CKinking of the ventilator tubing呼吸器管路是否扭結
- DTension pneumothorax張力性氣胸
— Explanation · 中文詳解 —
呼吸器高壓警報最常見原因是氣道阻力增加，痰液阻塞為臨床最常發生且需立即清除之項目。雖然管路扭曲（C）也常見，但痰液堵塞呼吸道會直接造成換氣失敗，必須優先評估與抽吸。氣胸（D）則為較嚴重之併發症，需評估胸部起伏後才能確認。
High-pressure alarms on mechanical ventilators most commonly indicate increased airway resistance, with secretions being the primary and most immediate cause. The nurse must first assess and clear the airway via suctioning to restore ventilation before investigating other potential causes such as tubing kinks or pneumothorax.
✦ 台美臨床差異
美國重症單位（ICU）護理師自主抽痰權限較大，台灣則需嚴格遵守醫囑或評估指徵以避免頻繁抽吸造成黏膜傷害。