護理師照護一位全髖關節置換術後 24 小時的病人。病人突然出現劇烈胸痛與呼吸困難。護理師應首先採取哪項行動？
A nurse is caring for a client who is 24 hours postoperative following a total hip arthroplasty. The client suddenly develops sharp chest pain and dyspnea. Which action should the nurse take first?
- AObtain an EKG to rule out myocardial infarction取得心電圖以排除心肌梗塞
- BApply supplemental oxygen via nasal cannula✓ 正解經鼻導管給予補充氧氣
- CEncourage the client to use the incentive spirometer鼓勵病人使用誘發性肺量計
- DCheck the surgical site for signs of bleeding檢查手術部位是否有出血跡象
骨科大手術（如髖關節置換）後出現突發性胸痛與呼吸困難，高度懷疑發生了肺栓塞（Pulmonary Embolism, PE）。這屬於生理適應領域中的循環與氧合急症。護理首要原則是 ABC：穩定氣道與呼吸。給予氧氣（B）能立即提高血氧飽和度，減輕缺氧造成的肺血管收縮，改善氧合並緩解呼吸困難，這是最優先的護理介入。誘發性肺量計（C）用於預防肺炎或肺塌陷，對已發生的栓塞無益；檢查傷口（D）與心電圖（A）雖是後續評估，但不能優先於穩定病人的氧合。在懷疑 PE 時，護理師應立即給氧、抬高床頭、測量生命徵象並通知醫療小組。
The sudden onset of chest pain and dyspnea post-hip surgery suggests a pulmonary embolism, making oxygenation the priority under the ABC framework. Applying supplemental oxygen immediately addresses life-threatening hypoxemia and improves tissue oxygenation. Other assessments like EKGs or incentive spirometry are secondary to stabilizing the client's respiratory status.
在美國護理實務中，護理師對於術後肺栓塞的警覺性極高，且通常擁有 Standing Order 可以在血氧下降時立即給予 2L 氧氣。台灣護理師亦具備此判斷力，但在法律層面，給氧通常需隨後補足醫師醫囑，處置思路上兩地完全一致。