— 生理適應 · MEDIUM · MCQ —
一位病人因氣喘急性發作入院。護理師的初步評估應著重於何處？
A client is admitted with acute exacerbation of asthma. The nurse's initial assessment should focus on:
- AWheezing and use of accessory muscles喘鳴及使用輔助呼吸肌
- BOxygen saturation and respiratory rate✓ 正解血氧飽和度與呼吸頻率
- CRecent medication compliance近期的用藥順從性
- DClient's understanding of triggers病人對誘發因子的了解
— Explanation · 中文詳解 —
氣喘急性發作時，遵循 ABC（Airway, Breathing, Circulation）原則，呼吸狀態評估為最高優先。血氧飽和度（SpO2）與呼吸速率（Respiratory rate）能最客觀且即時地反映病人的通氣狀況與缺氧程度。雖然喘鳴聲和呼吸肌使用也是重要指標，但 SpO2 是量化缺氧風險的關鍵數據，決定了是否需要立即給氧或更積極的呼吸治療。
During an acute asthma exacerbation, the nurse's initial assessment must prioritize breathing status according to ABC principles. Oxygen saturation and respiratory rate provide the most objective and immediate indicators of hypoxemia severity and ventilation adequacy. While wheezing and accessory muscle use are relevant, quantifying oxygen levels is critical for determining the urgency of interventions like supplemental oxygen.