# 一位氣切病患有粗糙的呼吸音、管內可見分泌物，且咳嗽無效。護理師應採取哪項行動？ > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=498501&lang=zh-tw > language: zh-TW > subject: Assistive Devices > category: BCC ## 題目 一位氣切病患有粗糙的呼吸音、管內可見分泌物，且咳嗽無效。護理師應採取哪項行動？ ## 選項 1. 每次抽吸前將生理食鹽水滴入氣切管內 2. 即使沒有分泌物，仍每 2 小時定時抽吸 3. 先給病患預先氧合，並使用無菌技術進行抽吸 **✔ 正確答案** 4. 持續抽吸 30 秒以完全清除分泌物 **正確答案: 3** ## 解析 粗糙呼吸音、可見分泌物和無效咳嗽表示需要抽吸。預先氧合可降低低血氧風險，開放式抽吸需使用無菌技術；應避免常規滴入生理食鹽水和長時間抽吸。 ## 深入解析 快速解答 先給病患預先氧合，並使用無菌技術抽吸。這些發現顯示氣道內有滯留的分泌物，操作過程應限制感染和低血氧風險。 為什麼這是正確的 病患無法有效清除可見的分泌物。抽吸可恢復氣道通暢，而事先給氧可在短暫通氣中斷期間增加儲備，無菌開放式技術則可減少污染。 簡單比喻或心智圖像 抽吸就像在確保人有足夠空氣儲備後，清理堵塞的吸管。這個比喻說明了通暢和準備，但未設定導管尺寸、壓力、持續時間或監測要求。 記憶掛鉤 分泌物加上無效咳嗽，意味著要預先氧合、使用無菌技術，並依需要短暫抽吸。 NCLEX 決策規則 對於人工氣道，應在評估顯示有滯留分泌物時抽吸，而非按固定時間表。先預先氧合，開放式抽吸使用無菌技術，並避免常規滴入生理食鹽水或長時間抽吸。 為什麼其他選項是錯的 常規滴入生理食鹽水可能造成傷害，且無法改善清除效果。固定時間抽吸忽略了評估，而持續抽吸 30 秒會增加低血氧和黏膜損傷風險。參考文獻 - [1]NCSBN: 2026 NCLEX-RN Test PlanNational Council of State Boards of Nursing - [2]AARC: Artificial Airway Suctioning Clinical Practice GuidelineAmerican Association for Respiratory Care ## 相同主題題目 - [A client after a stroke coughs when drinking thin liquids. Which nursing action best promo…](https://mymerci.kr/pages/nclex_q.php?qn_id=396624&lang=zh-tw) - [A client with left-leg weakness is learning to walk with a cane. Which statement by the cl…](https://mymerci.kr/pages/nclex_q.php?qn_id=497755&lang=zh-tw) - [An older adult with hearing loss repeatedly asks the nurse to repeat discharge instruction…](https://mymerci.kr/pages/nclex_q.php?qn_id=497912&lang=zh-tw) - [A client with low vision says, "I cannot read the medication labels or discharge sheet." W…](https://mymerci.kr/pages/nclex_q.php?qn_id=498096&lang=zh-tw) - [A client receiving chemotherapy has painful oral mucositis. Which instruction should the n…](https://mymerci.kr/pages/nclex_q.php?qn_id=498282&lang=zh-tw) - [An older adult with severe knee osteoarthritis is continent at home but has repeated urina…](https://mymerci.kr/pages/nclex_q.php?qn_id=498701&lang=zh-tw) - [A client with Meniere disease suddenly reports that the room is spinning and begins to los…](https://mymerci.kr/pages/nclex_q.php?qn_id=498733&lang=zh-tw) - [A client with Bell palsy cannot completely close the affected eye. Which instruction is mo…](https://mymerci.kr/pages/nclex_q.php?qn_id=498734&lang=zh-tw) ## 以其他語言閱讀 - [en](https://mymerci.kr/pages/nclex_q.php?qn_id=498501&lang=en) - [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=498501&lang=ko) - [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=498501&lang=ja) - [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=498501&lang=zh-tw) - [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=498501&lang=vi) --- More free questions: [NCLEX-RN 題庫](https://mymerci.kr/pages/nclex_bank.php?lang=zh-tw) _僅供學習參考。實際臨床請遵循最新指引與所屬機構規範。_