— 降低風險 · MEDIUM · MCQ —
護理師監測經股動脈心導管術後的病人。下列哪項評估發現最令人擔心？
The nurse is monitoring a client post-cardiac catheterization via the femoral artery. Which assessment finding is most concerning?
- ACool, pale extremity distal to the puncture site✓ 正解穿刺點遠端肢體冰冷蒼白
- BReports of mild discomfort when moving in bed報告在床上移動時有輕微不適
- CSmall amount of bruising at the insertion site插入部位有少量瘀青
- DStrong pedal pulses bilaterally雙側足背脈搏強勁
— Explanation · 中文詳解 —
心導管術後最嚴重的血管併發症是血栓或動脈夾層導致的末梢缺血。受術肢體遠端冰冷、蒼白是動脈血流受阻的典型徵象，需立即處理以防組織壞死。輕微瘀青是預期發現；脈搏強健是正常好現象；移動時輕微不適屬正常傷口反應。
Cool, pale skin distal to the puncture site indicates arterial insufficiency or occlusion, which is a medical emergency requiring immediate intervention to prevent tissue necrosis. Mild discomfort, minor bruising, and strong pedal pulses are expected or positive findings that do not suggest compromised circulation.
✦ 台美臨床差異
美國現多推廣經橈動脈導管以減少併發症；台灣股動脈與橈動脈皆常見，護理師對傷口加壓止血與評估流程一致。