— 降低風險 · HARD · MCQ —
護理師評估疑似氣胸的病人，下列何項發現最需要立即回報醫師？
A nurse is performing an assessment on a client with a suspected pneumothorax. Which finding is the most critical to report to the healthcare provider immediately?
- ATracheal deviation toward the unaffected side✓ 正解氣管向未受損側偏移
- BDiminished breath sounds on the affected side患側呼吸音減弱
- CPleural pain during inspiration吸氣時胸膜疼痛
- DSubcutaneous emphysema皮下氣腫
— Explanation · 中文詳解 —
氣管偏移（Tracheal deviation）是張力性氣胸（Tension pneumothorax）的晚期徵兆，表示胸內壓急劇升高並造成縱隔移位，將壓迫大血管導致心輸出量銳減及休克。這是危急生命的情況，需立即處理。
Tracheal deviation toward the unaffected side is a critical sign of tension pneumothorax, indicating a life-threatening mediastinal shift that compresses major vessels and reduces cardiac output. This requires immediate intervention to relieve intrathoracic pressure and prevent cardiovascular collapse.
✦ 台美臨床差異
美國護理師依權限可直接啟動緊急醫療應變小組；台灣多需由專科護理師或醫師評估後進行減壓。