護理師照護一位剛進行甲狀腺切除術的病人。下列哪項發現是護理師需優先回報醫師的?
A nurse is caring for a client who has just returned from a thyroidectomy. Which of the following findings is the highest priority for the nurse to report to the surgeon?
- ABlood pressure is 128/82 mmHg血壓為 128/82 mmHg
- BPatient complains of a sore throat病患抱怨喉嚨痛
- CIncision site dressing is dry and intact切口處敷料乾燥且完整
- DPatient is experiencing stridor✓ 正解病患出現喉鳴聲
甲狀腺切除術(Thyroidectomy)後,最危險的併發症是喉頭水腫(Laryngeal edema)或術後出血導致的氣道壓迫。喉鳴聲(Stridor)是一種高頻的呼吸音,代表氣道狹窄,是呼吸道阻塞的緊急徵兆。護理師應將氣道安全(Airway)列為最優先順序(Priority),任何暗示氣道受阻的發現皆須立即回報醫師,以便進行緊急處置或插管。
The most dangerous complication after a thyroidectomy is laryngeal edema or airway compression from postoperative bleeding. Stridor is a high-pitched respiratory sound that indicates airway narrowing and is an emergency sign of airway obstruction. The nurse must prioritize airway safety; any finding suggesting airway compromise must be reported immediately to the physician so that emergency measures or intubation can be performed.