— 照護管理 · EASY · MCQ —
護理師需評估四位病人，應優先評估哪位？
A nurse is prioritizing care for four clients. Which client should the nurse assess first?
- AA client with a well-healed surgical incision手術切口癒合良好的病人
- BA client with a hemoglobin level of 9.0 g/dL血紅素濃度為 9.0 g/dL 的病人
- CA client reporting sudden onset of shortness of breath✓ 正解主訴突然發作呼吸困難的病人
- DA client waiting for discharge instructions for diabetes等待糖尿病衛教出院指導的病人
— Explanation · 中文詳解 —
在優先順序評估中，護理師必須依據「ABC（Airway, Breathing, Circulation）」原則進行判斷。突然發生的呼吸急促（Shortness of breath）顯示呼吸系統可能存在急性功能障礙，如肺栓塞（PE）、氣胸或嚴重哮喘，這些情況若不立即處理，將迅速導致缺氧及心跳停止。相比之下，血紅素數值偏低、預備出院或傷口癒合狀況，均不屬於立即威脅生命的緊急狀態。
In priority assessment the nurse must follow the ABC (Airway, Breathing, Circulation) principle. The sudden onset of shortness of breath suggests acute respiratory system dysfunction such as pulmonary embolism, pneumothorax, or severe asthma; if not treated immediately these conditions can rapidly cause hypoxia and cardiac arrest. By comparison, a low hemoglobin value, an upcoming discharge, or wound-healing status are not immediately life-threatening.