— 降低風險 · HARD · MCQ —
一位病人被診斷為氣胸（pneumothorax）。哪項評估為優先？
A client is diagnosed with a pneumothorax. What is the priority assessment?
- APresence of tracheal deviation氣管偏移之存在
- BRespiratory rate and effort✓ 正解呼吸頻率與努力程度
- CPain level at the chest wall胸壁疼痛程度
- DPresence of a productive cough產痰性咳嗽之存在
— Explanation · 中文詳解 —
氣胸病人首重呼吸通暢程度。呼吸頻率與用力狀況（呼吸窘迫跡象）能直接反應氣胸對氣體交換的影響程度。雖然氣管偏移（tracheal deviation）是張力性氣胸的嚴重指標，但呼吸狀態的持續監測是基礎中的基礎。
For a client with a pneumothorax, the priority assessment is monitoring respiratory rate and effort to evaluate gas exchange. Although tracheal deviation indicates tension pneumothorax, continuous monitoring of respiratory status is the foundational assessment for determining the immediate impact of the air leak.
✦ 台美臨床差異
美台臨床皆將「呼吸窘迫指數」作為評估氣胸嚴重度的標準護理指標。