— 基本照護與舒適 · MEDIUM · MCQ —
護理師照護一位正在接受氧氣治療的病人。下列哪項發現顯示需要進一步評估？
A nurse is caring for a client receiving oxygen therapy. Which finding indicates the need for further assessment?
- ASpO2 of 95% on room air室溫下血氧飽和度 95%
- BPatient is sleeping comfortably病人安穩入睡
- CRestlessness and irritability✓ 正解煩躁不安與易怒
- DOxygen flow rate is 2 L/min氧氣流量為 2 L/min
— Explanation · 中文詳解 —
對於接受氧氣治療的病人，護理師應持續監測氧合狀況。躁動（Restlessness）與易怒（Irritability）是缺氧（Hypoxia）非常早期的神經系統徵象，即使在給氧狀態下出現這些症狀，也可能代表氧氣治療未達預期目標，或病人氣道發生阻塞。護理師必須立即重新評估病人的呼吸狀況、血氧飽和度（SpO2）及肺部聽診，以排除急性缺氧風險。
Restlessness and irritability are early neurological signs of hypoxia, indicating that the client may not be receiving adequate oxygenation despite therapy. The nurse must immediately reassess respiratory status, SpO2, and lung sounds to rule out acute hypoxia or airway obstruction.