— 降低風險 · HARD · SATA —
護理師照護一位新置入中央靜脈導管（PICC）的病人，下列哪些評估發現顯示可能出現併發症，需立即處理？（選所有適合的）
A nurse is caring for a client with a new peripherally inserted central catheter (PICC). Which assessment findings indicate a potential complication that requires immediate intervention? (Select all that apply.)
- ASwelling in the ipsilateral arm✓ 正解同側手臂腫脹
- BClient report of muffled sounds near the ear✓ 正解病患主訴耳邊有悶塞聲
- CInability to aspirate blood from the catheter✓ 正解無法從導管抽回血液
- DRedness and warmth at the insertion site✓ 正解置入部位紅腫發熱
- EThe catheter length externally has increased by 3 cm✓ 正解導管外部長度增加 3 公分
— Explanation · 中文詳解 —
PICC 導管併發症評估包括：患側肢體腫脹提示血栓；聽見耳邊異音可能與導管位置偏移至頸靜脈有關；無法抽回血指示阻塞；紅腫溫熱提示感染或靜脈炎；導管外露長度增加表示導管移位。上述皆需立即報告並暫停使用。
Complications of a PICC line include unilateral arm swelling indicating thrombosis, muffled sounds suggesting catheter migration into the internal jugular vein, inability to aspirate blood due to obstruction, redness and warmth indicating infection, and increased external length showing catheter displacement.
✦ 台美臨床差異
美國 PICC 放置多由專科護理師或放射科醫師執行；台灣多由專科醫師執行，護理師監測重要性極高。