# 一位罹患鐮狀細胞疾病的個案因血管阻塞性疼痛發作而住院。個案體溫 38.6°C，出現新的胸痛和咳嗽，且在未使用氧氣下血氧飽和度為 88%。護理師應首先採取哪一項行動？ > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=498696&lang=zh-tw > language: zh-TW > subject: Medical Emergencies > category: PA ## 題目 一位罹患鐮狀細胞疾病的個案因血管阻塞性疼痛發作而住院。個案體溫 38.6°C，出現新的胸痛和咳嗽，且在未使用氧氣下血氧飽和度為 88%。護理師應首先採取哪一項行動？ ## 選項 1. 給予氧氣並通知醫療團隊進行緊急評估 **✔ 正確答案** 2. 給予處方的口服鴉片類藥物，並於一小時後重新評估疼痛 3. 鼓勵口服液體，並在活動後重新測量血氧飽和度 4. 使用誘發性肺量計，並等待預定的胸部 X 光檢查 **正確答案: 1** ## 解析 鐮狀細胞疾病患者出現發燒、新的胸部症狀和低血氧，暗示急性胸部症候群，這是一種可能危及生命的併發症。氧氣支持和緊急團隊評估優先於常規疼痛治療、活動或延遲檢查。 ## 深入解析 快速解答 給予氧氣並取得緊急評估。此模式暗示急性胸部症候群且目前有低血氧。 為什麼這是正確的 急性胸部症候群可能迅速惡化，可能需要住院治療，如氧氣、抗生素和輸血。在緊急通報新的呼吸系統發現的同時支持氧合，可處理立即的威脅。 簡單比喻或心智圖像 新的胸部發現就像一個警示燈，顯示疼痛危機已轉移到肺部。氧氣和緊急評估是對該警示的回應，但這個比喻無法確立最終診斷，也無法取代影像學和實驗室評估。 記憶掛鉤 鐮狀細胞疾病加上發燒、胸部症狀和低血氧，意味著要懷疑急性胸部症候群並緊急行動。 NCLEX 決策規則 當鐮狀細胞疾病個案出現新的呼吸道症狀和低血氧時，應優先給予氧氣並緊急通報，以處理可能的急性胸部症候群。不要讓既有的疼痛診斷掩蓋新的呼吸道或呼吸威脅。 為什麼其他選項是錯的 口服鴉片類藥物無法治療呼吸道緊急狀況。活動可能增加氧氣需求，而僅使用誘發性肺量計不應延遲緊急評估，尤其是當出現低血氧和新的胸部症狀時。參考文獻 - [1]NCSBN: 2026 NCLEX-RN Test PlanNational Council of State Boards of Nursing - [2]NHLBI: Sickle Cell Disease Symptoms and Acute Chest SyndromeNational Heart, Lung, and Blood Institute ## 相同主題題目 - [A nurse is caring for an alert adult client with type 1 diabetes who reports tremors, swea…](https://mymerci.kr/pages/nclex_q.php?qn_id=360524&lang=zh-tw) - [A 68-year-old client with COPD is admitted with shortness of breath and SpO2 86% on room a…](https://mymerci.kr/pages/nclex_q.php?qn_id=362940&lang=zh-tw) - [A 58-year-old client arrives at the emergency department with crushing substernal chest pa…](https://mymerci.kr/pages/nclex_q.php?qn_id=362976&lang=zh-tw) - [A 72-year-old client is brought to the emergency department by family who report that the …](https://mymerci.kr/pages/nclex_q.php?qn_id=363003&lang=zh-tw) - [A 79-year-old client is admitted from a long-term care facility with diarrhea, decreased o…](https://mymerci.kr/pages/nclex_q.php?qn_id=363089&lang=zh-tw) - [A nurse is caring for a client prescribed Digoxin. Which nursing action is most appropriat…](https://mymerci.kr/pages/nclex_q.php?qn_id=375157&lang=zh-tw) - [A nurse is caring for a client prescribed Lithium. Which nursing action is most appropriat…](https://mymerci.kr/pages/nclex_q.php?qn_id=375233&lang=zh-tw) - [A nurse is caring for a client prescribed Spironolactone. Which nursing action is most app…](https://mymerci.kr/pages/nclex_q.php?qn_id=391869&lang=zh-tw) ## 以其他語言閱讀 - [en](https://mymerci.kr/pages/nclex_q.php?qn_id=498696&lang=en) - [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=498696&lang=ko) - [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=498696&lang=ja) - [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=498696&lang=zh-tw) - [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=498696&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。_