— 降低風險 · EASY · MCQ —
一位病人急性氣喘發作。護理師最優先的評估項目為何？
A client is experiencing an acute asthma attack. What is the nurse's priority assessment?
- ASkin temperature and turgor皮膚溫度和彈性
- BPupil reaction瞳孔反應
- CBreath sounds and respiratory effort✓ 正解呼吸音和呼吸努力程度
- DHeart rate and blood pressure心率和血壓
— Explanation · 中文詳解 —
氣喘發作時，呼吸道阻塞導致通氣障礙，首要評估為呼吸狀態（聽診是否有哮鳴音、是否使用呼吸輔助肌、呼吸頻率），以確認呼吸衰竭風險。心跳與血壓是評估循環， pupillary reaction 是神經學評估，均非氣喘發作的首要重點。
During an acute asthma attack, the primary concern is respiratory compromise due to airway obstruction and impaired gas exchange. Assessing breath sounds and respiratory effort allows the nurse to evaluate the severity of bronchoconstriction and determine the immediate need for interventions to maintain airway patency.
✦ 台美臨床差異
美台皆將呼吸音評估列為氣喘照護的核心，美國護理師常在評估後直接依據 protocol 給藥。