— 降低風險 · HARD · SATA —
護理師對疑似氣胸的病人進行評估，下列哪些發現需要立即介入？（選所有適合的）
A nurse is performing a focused assessment on a client with a suspected pneumothorax. Which finding requires immediate intervention? (Select all that apply.)
- ATracheal deviation✓ 正解氣管偏移
- BAbsent breath sounds on the affected side✓ 正解患側呼吸音消失
- CRespiratory rate of 18 breaths/min呼吸速率 18 次/分
- DTachycardia✓ 正解心跳過速
- EHypotension✓ 正解低血壓
— Explanation · 中文詳解 —
氣胸（特別是張力性氣胸）會導致胸腔壓力急遽上升，進而壓迫心臟與大血管，產生氣管偏移、患側呼吸音消失、心跳過快與低血壓等休克症狀。呼吸速率 18 次/分屬於正常範圍，故無須立即介入。此病況需立即執行減壓措施。
Tracheal deviation, absent breath sounds, tachycardia, and hypotension are critical signs of a tension pneumothorax, a life-threatening emergency requiring immediate decompression. These symptoms result from increased intrathoracic pressure compromising cardiac output and lung expansion. A respiratory rate of 18 breaths/min is within normal limits and does not require immediate intervention.
✦ 台美臨床差異
張力性氣胸在美國通常由護理師協助並準備穿刺；台灣在急診或 ICU 現場，護理師需快速備妥胸管引流用物，並協助醫師執行穿刺。