— 生理適應 · EASY · MCQ —
病人預計進行心導管檢查。下列哪項術後照護措施為必須？
A client is scheduled for a cardiac catheterization. Which nursing intervention is essential in the post-procedure care?
- ACheck the distal pulses of the affected extremity✓ 正解檢查患側肢體的遠端脈搏
- BEncourage weight-bearing to prevent blood clots鼓勵負重以防止血栓形成
- CApply a cold compress to the puncture site for 24 hours在穿刺部位冷敷 24 小時
- DAdminister aspirin every hour每小時給予阿斯匹靈
— Explanation · 中文詳解 —
心導管檢查（Cardiac Catheterization）術後，最嚴重的併發症是穿刺部位（通常為股動脈或橈動脈）的出血或血栓形成，導致遠端肢體缺血。護理師必須定期檢查遠端脈搏（Distal pulses）、膚色、溫度與感覺（Neurovascular assessment）。若脈搏減弱或消失，代表可能發生血管閉塞，需立即通報醫師，此為確保病人安全的首要任務。
Post-cardiac catheterization, the priority nursing intervention is assessing the distal pulses, skin color, temperature, and sensation of the affected extremity to detect vascular occlusion or ischemia. Early identification of compromised circulation is critical to prevent severe complications such as tissue necrosis.