— 降低風險 · MEDIUM · SATA —
護理師照護一位疑似氣胸的病人，應監測哪些臨床表徵？（選所有適合的）
A nurse is caring for a client with a suspected pneumothorax. Which clinical manifestations should the nurse monitor for? (Select all that apply.)
- ATachycardia✓ 正解心搏過速
- BAbsent breath sounds on the affected side✓ 正解患側呼吸音消失
- CTracheal deviation toward the affected side氣管向患側偏移
- DSudden sharp chest pain✓ 正解突發性尖銳胸痛
- EHyperresonance on percussion✓ 正解叩診呈過度共振音
— Explanation · 中文詳解 —
氣胸病人因胸膜腔壓力改變，常表現為突發性銳利胸痛、患側呼吸音消失與叩診呈過度回響音（Hyperresonance）。因缺氧與交感神經興奮常出現心跳過速。C選項錯誤：氣管偏移（Tracheal deviation）僅見於張力性氣胸且通常偏移向「健側」而非患側，故不選。
Clinical manifestations of pneumothorax include sudden sharp chest pain, absent breath sounds on the affected side, hyperresonance to percussion, and tachycardia due to hypoxia. Tracheal deviation is not typically present unless it progresses to a tension pneumothorax, in which case it deviates away from the affected side.
✦ 台美臨床差異
氣胸處理在美台皆由胸腔科醫師決定是否置放胸管，護理師需負責監控生命徵象變化。