— 生理適應 · MEDIUM · MCQ —
護理師照護一位全髖關節置換術後，突發呼吸困難與心跳過速的病人。下列哪項措施優先級最高？
A nurse is caring for a client who develops a sudden onset of dyspnea and tachycardia following a total hip arthroplasty. Which intervention is the highest priority?
- APerform a focused lung assessment進行專注的肺部評估
- BAdminister oxygen via nasal cannula✓ 正解經鼻導管給予氧氣
- CObtain a bedside electrocardiogram取得床旁心電圖
- DElevate the head of the bed to 45 degrees將床頭抬高至 45 度
— Explanation · 中文詳解 —
術後病人突發呼吸困難（Dyspnea）與心跳過速（Tachycardia），依據 ABC（氣道、呼吸、循環）優先原則，首要考量為肺栓塞（PE）。肺栓塞會導致通氣/灌流（V/Q）失調，造成低血氧。給予氧氣（Oxygenation）是維持組織代謝、預防心肌缺氧與腦部損傷的最關鍵處置。其他選項如心電圖或肺部評估雖是必要診斷過程，但給氧能立即改善生命徵象穩定性，應置於首位。
Based on the ABC priority framework, ensuring adequate oxygenation is the most critical intervention for a client with suspected pulmonary embolism to prevent tissue hypoxia. While assessment and diagnostic tests are necessary, administering oxygen directly addresses the life-threatening hypoxemia and stabilizes the client immediately.