— 降低風險 · EASY · MCQ —
一位病人剛完成心導管檢查返回病房，下列何者為護理師優先進行的評估項目？
A nurse is caring for a client who has just returned to the unit following a cardiac catheterization. Which of the following is the priority assessment?
- AMonitor distal pulses in the affected extremity✓ 正解監測患側肢體的遠端脈搏
- BEvaluate the client's level of consciousness評估病人的意識程度
- CAssess vital signs評估生命徵象
- DCheck the insertion site for bleeding檢查插入部位是否有出血
— Explanation · 中文詳解 —
心導管檢查後，護理目標在於維持血液循環與評估併發症。監測受檢側肢體的遠端脈搏（足背脈搏）是優先事項，因為這能立即偵測到因血腫或栓塞造成的循環中斷。若發生動脈閉塞，肢體可能在短時間內壞死，因此脈搏評估的優先級高於穿刺處檢查或生命徵象測量。
After cardiac catheterization, monitoring distal pulses in the affected extremity is the priority to detect acute limb ischemia caused by thrombus or hematoma. Immediate assessment of circulation is critical because arterial occlusion can lead to rapid tissue necrosis if not addressed promptly.
✦ 台美臨床差異
美台臨床對於心導管術後病人均有嚴格的觀察間隔流程（如 Q15min 頻率），差異不大。