— 生理適應 · HARD · MCQ —
病人疑似肺栓塞住院，下列哪項評估發現最令護理師擔憂？
A client is admitted with a diagnosis of potential pulmonary embolism. Which assessment finding is most concerning to the nurse?
- AOxygen saturation of 88% despite 2L oxygen✓ 正解即使給予2公升氧氣，血氧飽和度仍為88%
- BHeart rate of 110 beats per minute心率为每分钟110次
- CSudden onset of pleuritic chest pain突然出現胸膜性胸痛
- DAnxiety and a sense of impending doom焦慮與臨終感
— Explanation · 中文詳解 —
肺栓塞導致換氣與灌流不匹配，最緊急的生理指標是缺氧。雖然胸痛、心跳過速與焦慮皆為常見症狀，但 SpO2 88% 代表氣體交換功能受損嚴重，已威脅到生命安全，屬於呼吸衰竭的徵兆，需優先採取人工呼吸道維護或高流量氧氣處置。
Hypoxemia refractory to supplemental oxygen, indicated by an oxygen saturation of 88%, is the most critical finding as it signifies severe gas exchange impairment. While tachycardia, chest pain, and anxiety are common symptoms of pulmonary embolism, they are compensatory or secondary responses. Immediate intervention is required to address the life-threatening respiratory failure and ensure adequate tissue oxygenation.
✦ 台美臨床差異
美國護理師常主導執行 D-dimer 篩檢與 CT 排程建議，台灣多依醫師指示進行診斷流程。