# 護理師聆聽一位成年個案運動後在二尖瓣區所錄得的錄音。下列哪一項紀錄最為準確？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=620077&lang=zh-tw  
> language: zh-TW  
> subject: Lifestyle Choices  
> category: HPM

## 題目

護理師聆聽一位成年個案運動後在二尖瓣區所錄得的錄音。下列哪一項紀錄最為準確？

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🎧Cardiac auscultation recording

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1

規律的心跳速率，接近每分鐘60次

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2

快速且規律的心跳速率，接近每分鐘150次

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3

不規則的不規律心律，伴隨強度變異

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4

S2之後出現的低頻額外心音

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## 解析

該錄音包含規律成對的心音，速率快速，約為每分鐘150次。由於此心音是在運動後錄製的，護理師應記錄所觀察到的速率與規律性，再將其與個案評估結果進行關聯，而非僅憑錄音就下病理診斷。

## 深入解析

快速解答
該錄音包含規律成對的心音，速率快速，約為每分鐘150次。由於此心音是在運動後錄製的，護理師應記錄所觀察到的速率與規律性，再將其與個案評估結果進行關聯，而非僅憑錄音就下病理診斷。
關鍵線索
運用情境中的發現與時機來判斷最安全的回應。
臨床推理
將相關線索與有實證支持的護理判斷與行動連結起來。
為何其他選項不適用
其他回應在此情境中缺乏依據、時機不當、優先順序較低或不完整。
優先順序與安全
先處理立即性威脅，並在介入後重新評估。
重點摘要
對於快速且規律的心跳速率紀錄，應記錄所觀察到的發現，避免無依據的診斷推論。
音檔出處
ezwa - CC0-1.0
**參考資料**
- Open RN Nursing Skills: Cardiovascular Assessment

## 臨床情境

護理師聆聽一位成年個案運動後在二尖瓣區所錄得的錄音。下列哪一項紀錄最為準確？

## 重要概念

- **Tachycardia** — 成人心跳速率大於每分鐘100次。
- **Mitral area** — 靠近心尖的心臟聽診區。
- **Regular rhythm** — 每次心跳間距遵循一致規律模式的心律。

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