# 一位胸部鈍傷的個案出現嚴重呼吸困難、左側呼吸音消失、低血壓及氣管向右偏移。護理師應懷疑何種情況？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=397169&lang=zh-tw  
> language: zh-TW  
> subject: Complications of Procedures  
> category: ROR

## 題目

一位胸部鈍傷的個案出現嚴重呼吸困難、左側呼吸音消失、低血壓及氣管向右偏移。護理師應懷疑何種情況？

## 選項

1. 張力性氣胸。 **✔ 正確答案**
2. 肋膜積液。
3. 肺擴張不全。
4. 肺栓塞。

**正確答案: 1**

## 解析

單側呼吸音消失、低血壓、嚴重呼吸窘迫及氣管偏離患側，是張力性氣胸的典型線索。此為緊急情況。肋膜積液、肺擴張不全及肺栓塞不符合完整的創傷及縱膈腔偏移模式。

## 深入解析

臨床判斷
利用個案線索、時間點、檢驗數據及安全風險，選擇最符合胸部創傷張力性氣胸的回應。

記憶提示
將最強的線索群與最安全的護理判斷配對。

KR vs US
NCLEX考題獎勵基於線索的優先思考，而非單獨的記憶。

## 臨床情境

臨床實務指引
針對胸部創傷張力性氣胸，將完整的線索模式與個案當前的穩定性、醫囑數據及預期的護理範圍進行比較。

注意
當完整情境改變了優先次序或安全性時，不要僅根據單一線索選擇行動。

## 重要概念

- **張力性氣胸** — 空氣在肋膜腔內受壓積聚，影響通氣和循環。
- **氣管偏移** — 氣管移位，可能因胸腔內壓力變化而發生。
- **胸部鈍傷** — 胸部非穿透性損傷，可能損害肺部或血管。

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