# 一位術後個案突然出現呼吸急促、尖銳胸痛，且血氧飽和度為88%。護理師應首先採取哪項行動？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=394143&lang=zh-tw  
> language: zh-TW  
> subject: Medical Emergencies  
> category: PA

## 題目

一位術後個案突然出現呼吸急促、尖銳胸痛，且血氧飽和度為88%。護理師應首先採取哪項行動？

## 選項

1. 給予氧氣並通知快速反應小組或醫師。 **✔ 正確答案**
2. 鼓勵個案在走廊行走。
3. 給予制酸劑並在飯後重新評估。
4. 將個案置於垂頭仰臥式。

**正確答案: 1**

## 解析

術後突發呼吸困難、肋膜性胸痛和低血氧，暗示可能為肺栓塞。護理師應支持氧合作用並迅速升級照護。下床活動或延遲評估可能使情況惡化。

## 深入解析

臨床判斷
術後急性低血氧是呼吸急症，除非證實為其他原因。

記憶提示
術後突發呼吸困難：考慮肺栓塞。

## 臨床情境

臨床實務指引
肺栓塞的評估需考量突發呼吸困難、胸痛、心搏過速、低血氧，以及手術或不活動等危險因子。

注意事項
在疑似急性栓塞期間，勿鼓勵活動。

## 重要概念

- **肺栓塞** — 肺循環中的阻塞，通常來自血塊。
- **低血氧症** — 血液中氧氣濃度過低。
- **肋膜性胸痛** — 呼吸時加劇的尖銳胸痛。

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