# 心臟術後，個案出現低血壓、頸靜脈怒張、心音模糊且脈壓變窄。護理師應先採取哪項行動？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=498091&lang=zh-tw  
> language: zh-TW  
> subject: Medical Emergencies  
> category: PA

## 題目

心臟術後，個案出現低血壓、頸靜脈怒張、心音模糊且脈壓變窄。護理師應先採取哪項行動？

## 選項

1. 放低床頭並在常規輸液後重新評估
2. 鼓勵頻繁咳嗽和深呼吸以擴張術後肺部
3. 啟動緊急應變並準備緊急心包膜引流 **✔ 正確答案**
4. 給予醫囑利尿劑以減少頸靜脈怒張

**正確答案: 3**

## 解析

這些發現顯示心包填塞，心室填充受損且心輸出量下降。這是一種阻塞性休克緊急情況，因此護理師應啟動緊急應變並準備緊急心包膜引流，而非延遲確定性治療。

## 深入解析

快速解答
將這些發現視為心包填塞。啟動緊急求助並準備緊急引流心包膜液體。

為什麼這是正確的
心臟周圍液體的壓力阻止心室填充，降低每搏輸出量和血壓，同時靜脈壓上升。心包穿刺術或手術引流可緩解造成阻塞的壓力。

簡單比喻或心智圖像
填塞就像一個堅固的袋子緊緊包住泵浦，使泵浦無法再填充。移除壓力可恢復填充，但此類比無法指出原因，也不能取代快速的血流動力學評估和復甦。

記憶掛鉤
靜脈外低壓加上頸部高壓加上心音微弱，意味著必須緩解心臟周圍的壓力。

NCLEX 決策規則
當心臟術後出現低血壓、靜脈怒張和心音模糊時，優先啟動緊急升級並準備心包膜引流。不要將頸靜脈視為單純的體液過多來處理。

為什麼其他選項是錯的
常規重新評估延遲了緊急治療。咳嗽無法緩解心包膜壓力，而利尿劑可能惡化填塞時的前負荷和心輸出量。參考文獻

- [1]NCSBN: 2026 NCLEX-RN Test PlanNational Council of State Boards of Nursing

- [2]AHA: Treatment of Pericarditis and Cardiac TamponadeAmerican Heart Association, reviewed 2026

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