— 生理適應 · HARD · MCQ —
一位病人疑似氣胸，下列哪項臨床表現是張力性氣胸的緊急徵象？
A client presents with a suspected pneumothorax. Which clinical manifestation is an urgent sign of tension pneumothorax?
- ATracheal deviation toward the unaffected side✓ 正解氣管向未受損側偏移
- BDyspnea and tachypnea呼吸困難與呼吸過速
- CPleuritic chest pain胸膜炎性胸痛
- DHyper-resonance on percussion叩診呈過音
— Explanation · 中文詳解 —
張力性氣胸（Tension Pneumothorax）是一種致命的緊急狀況。當胸膜腔內空氣單向進入無法排出，壓力迅速累積，不僅壓迫肺部，更會造成縱隔腔移位（Mediastinal shift），導致大血管受壓，回心血量驟減，引發阻塞性休克。氣管偏移至健側是臨床上極為緊急的徵象，護理師需立即通報並準備緊急減壓（如針刺減壓）。
Tracheal deviation toward the unaffected side is a critical late sign of tension pneumothorax, indicating mediastinal shift and compromised cardiac output. This finding requires immediate notification and preparation for emergency decompression to prevent obstructive shock.