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生理適應 · HARD · MCQ

護理師照護一位疑似肺栓塞的病人。優先的護理處置為何?

A nurse is caring for a client with a suspected pulmonary embolism. What is the priority nursing intervention?

  • APrepare for an ECG
    準備進行心電圖檢查
  • BObtain a chest X-ray
    取得胸部X光檢查
  • CInitiate an IV line
    建立靜脈通路
  • DAdminister oxygen✓ 正解
    給予氧氣
Explanation · 中文詳解

肺栓塞導致血氧過低與呼吸窘迫,第一優先級別為 ABC 中的呼吸(Breathing),給氧是改善低血氧的最直接措施。建立 IV 通路、胸部 X 光檢查與心電圖均重要,但必須在確保呼吸穩定之後才依序進行。

The priority nursing intervention for a client with a suspected pulmonary embolism is to administer oxygen, as hypoxemia is the most immediate life-threatening concern. While diagnostic tests like ECGs and chest X-rays are necessary, they do not address the acute respiratory distress. Establishing IV access is important but secondary to ensuring adequate oxygenation and breathing stability.

✦ 台美臨床差異

肺栓塞在美台臨床皆視為緊急危重症,護理流程皆要求快速啟動緊急醫療應變小組。

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