# 一位護理師在心尖處聽診一位成年病人。請聽錄音。護理師應記錄哪一項發現？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=620076&lang=zh-tw  
> language: zh-TW  
> subject: Lifestyle Choices  
> category: HPM

## 題目

一位護理師在心尖處聽診一位成年病人。請聽錄音。護理師應記錄哪一項發現？

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🎧Cardiac auscultation recording

Use headphones if available. You may replay the recording.

1

不規則的不規律心律

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2

約每分鐘70次的規律成對S1與S2型態

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3

每次S2後出現S3奔馬音

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4

粗糙的心包膜摩擦音

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## 解析

此錄音呈現快速且不規則的不規律心律，與心房顫動的聲學型態一致。護理師應記錄觀察到的速率與心律，並將此發現與脈搏、症狀及心電圖結果進行關聯，而非僅憑聲音下診斷。

## 深入解析

快速解答
此錄音呈現快速且不規則的不規律心律，與心房顫動的聲學型態一致。護理師應記錄觀察到的速率與心律，並將此發現與脈搏、症狀及心電圖結果進行關聯，而非僅憑聲音下診斷。
關鍵線索
使用情境中的發現與時機來辨識最安全的反應。
臨床推理
將相關線索與證據支持的護理判斷與行動連結。
為何其他選項不適用
其他反應在此情境中缺乏依據、時機錯誤、優先順序較低或不完整。
優先順序與安全
首先處理立即性威脅，並在介入後再評估。
重點提示
對於心房顫動聽診，應記錄觀察到的發現，避免無依據的診斷推論。
音檔出處
James Heilman, MD - CC-BY-SA-3.0
**參考資料**
- Open RN Nursing Skills: Cardiovascular Assessment

## 臨床情境

一位護理師在心尖處聽診一位成年病人。請聽錄音。護理師應記錄哪一項發現？

## 重要概念

- **Irregularly irregular rhythm** — 心搏之間無重複型態的心律。
- **Apical pulse** — 在心尖處評估的心跳速率與心律。
- **Electrocardiography** — 用於確認心律的電氣心律檢測。

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