# 有氣喘的個案表示呼吸急促與喘鳴加重。室內空氣下血氧飽和度為 90%。哪些護理措施適當？選出所有適用者。

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=393831&lang=zh-tw  
> language: zh-TW  
> subject: Medical Emergencies  
> category: PA

## 題目

有氣喘的個案表示呼吸急促與喘鳴加重。室內空氣下血氧飽和度為 90%。哪些護理措施適當？選出所有適用者。

1

評估呼吸音、呼吸作功與治療反應。

2

鼓勵在走廊行走以鬆動分泌物。

3

只提供口服液體，稍後再評估。

4

依醫囑給氧以改善氧合。

5

讓個案採 high-Fowler 姿勢。

6

給予醫囑的短效支氣管擴張劑。

## 解析

急性氣喘症狀合併低血氧需要協助氣道的姿勢、醫囑的快速緩解支氣管擴張劑、必要給氧，以及密切再評估呼吸狀態。急性發作時走動可能增加呼吸窘迫。僅給液體無法處理支氣管痙攣或氧合不良。

## 深入解析

臨床判斷
急性喘鳴合併低氧時，先支持通氣，給予醫囑快速緩解治療並再評估反應。

記憶重點
坐高、支氣管擴張、給氧、再評估。

## 臨床情境

實務指引
NHLBI 氣喘資料說明，嚴重發作或症狀未迅速改善時可需要快速緩解藥物、霧化治療、氧氣治療與緊急照護。

注意
胸部變安靜、疲憊、意識下降或持續低氧是急症。

## 重要概念

- **支氣管痙攣** — 氣道平滑肌收縮變窄，增加呼吸作功並造成喘鳴。
- **短效支氣管擴張劑** — 急性症狀時用來放鬆氣道平滑肌的快速緩解藥物。
- **低氧血症** — 血液氧氣低於預期，常可由低血氧飽和度反映。

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