— 降低風險 · HARD · MCQ —
護理師照護一名開胸術後病人，下列哪項評估發現需要立即護理介入？
A nurse is caring for a client who is post-operative following a thoracotomy. Which assessment finding requires immediate nursing intervention?
- ATracheal deviation toward the unaffected side✓ 正解氣管向未受損側偏移
- BPain level of 4/10 at the incision site切口處疼痛程度為 4/10
- COccasional bubbling in the water seal chamber水封瓶內偶有冒泡
- DSerosanguinous drainage in the chest tube胸管引流液呈血清血性
— Explanation · 中文詳解 —
開胸術後病人最嚴重的併發症之一是張力性氣胸（Tension Pneumothorax）。氣管偏移向健側（Tracheal deviation toward the unaffected side）是氣胸導致縱隔腔移位的典型臨床徵兆，這會嚴重阻礙靜脈回流並導致心輸出量下降，屬於需要立即急救的危急狀況。
Tracheal deviation toward the unaffected side is a critical sign of tension pneumothorax, a life-threatening emergency that causes mediastinal shift and compromises venous return. This finding requires immediate nursing intervention to prevent cardiovascular collapse. Other options, such as mild pain or serosanguinous drainage, are expected postoperative findings that do not require urgent action.