# 一位病人經由股動脈接受心導管檢查後返回。哪一項發現需要立即的護理處置？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=397458&lang=zh-tw  
> language: zh-TW  
> subject: Postsurgical Complications  
> category: ROR

## 題目

一位病人經由股動脈接受心導管檢查後返回。哪一項發現需要立即的護理處置？

## 選項

1. 病人表示術後感到疲倦。
2. 穿刺部位敷料清潔且乾燥。
3. 依醫囑將患側腿保持伸直。
4. 患側足部冰冷且足背動脈搏動消失。 **✔ 正確答案**

**正確答案: 4**

## 解析

股動脈心導管檢查後，足部冰冷且足背動脈搏動消失，暗示遠端灌流受損，需要立即處置。術後感到疲倦、敷料清潔以及腿部保持伸直是可預期的。動脈穿刺後，神經血管檢查至關重要。

## 深入解析

臨床判斷
利用病人線索、時機、檢驗數據及安全風險，選擇最符合心導管檢查後灌流狀況的回應。

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

臨床實踐指引
針對心導管檢查後灌流，將完整的線索模式與病人當前的穩定性、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順序或安全性時，切勿僅根據單一線索選擇行動。

## 重要概念

- **心導管檢查** — 一種用於評估或治療冠狀動脈及心臟狀況的侵入性檢查。
- **足背動脈搏動** — 足部的脈搏，用於評估遠端循環。
- **神經血管檢查** — 對循環、活動、感覺、溫度及脈搏的評估。

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