— 降低風險 · MEDIUM · MCQ —
護理師在內外科病房照護病人，哪位病人應優先評估？
A nurse is caring for a client on the medical-surgical unit. Which client should the nurse assess first?
- AA client with suspected pulmonary embolism who is complaining of sudden dyspnea✓ 正解主訴突然呼吸困難之疑似肺栓塞病人
- BA client with diabetes who has a blood glucose level of 180 mg/dL血糖值為 180 mg/dL 之糖尿病病人
- CA client with COPD who has a SpO2 of 90% on 2L oxygen在 2L 氧氣下 SpO2 為 90% 之 COPD 病人
- DA client who is 2 days post-op with a temperature of 38.3°C術後 2 天且體溫為 38.3°C 之病人
— Explanation · 中文詳解 —
優先順序遵循 ABC（氣道、呼吸、循環）原則。肺栓塞（A）是危及生命的急性狀態。A 的血糖稍高但非立即致命；B 的 SpO2 90% 符合 COPD 病人的目標設定；C 的術後發燒需評估，但穩定性優於急性呼吸困難的病人。因此 D 為最優先評估對象。
Prioritization follows the ABC (Airway, Breathing, Circulation) principles. Pulmonary embolism (A) is a life-threatening acute condition. The blood glucose in B is mildly elevated but not immediately life-threatening; the SpO2 of 90% in B meets the target for a COPD client; the postoperative fever in C requires assessment but is more stable than acute dyspnea. Therefore, A should be the priority for assessment.
✦ 台美臨床差異
臨床優先序（Triage）原則美台一致。美國護理師常使用 SBAR 工具快速交班並確認急迫性。