護理師正在為內外科病房的四位病人進行優先順序評估。哪一位病人應該優先接受評估？
A nurse is prioritizing care for four clients on a medical-surgical unit. Which client should the nurse assess first?
- AA client requesting pain medication for a migraine主訴偏頭痛而要求止痛藥的病人
- BA client with a scheduled dressing change for a surgical incision手術切口需定期換藥的病人
- CA client preparing for discharge with questions about medications準備出院並對用藥有疑問的病人
- DA client reporting sudden shortness of breath and chest pain✓ 正解主訴突然呼吸困難及胸痛的病人
護理師在進行優先順序評估時，必須嚴格遵循 ABC（Airway, Breathing, Circulation）原則。選項 D 的病人出現突發性呼吸困難與胸痛，這是肺栓塞（Pulmonary Embolism, PE）或急性心肌梗塞（MI）的典型徵象，屬於生命威脅等級。護理師必須優先評估此類病人，以確認呼吸循環狀態並採取緊急介入。其他選項雖需要處理，但相對穩定，不屬於立即致命的狀況。
When prioritizing care, the nurse must strictly follow the ABC (Airway, Breathing, Circulation) framework. The client in option D presents with sudden shortness of breath and chest pain, which are classic signs of pulmonary embolism (PE) or acute myocardial infarction (MI) and represent a life-threatening condition. The nurse must assess this client first to confirm respiratory and circulatory status and to initiate emergency intervention. The other options need attention but are relatively stable and not immediately life-threatening.