護理師在交班後接收到四位病人的資訊，應優先評估哪一位？
A nurse receives an end-of-shift report on four clients. Which client should the nurse assess first?
- AA client requesting assistance to transfer from bed to chair一位請求協助從床轉至椅上的病人
- BA client with an intravenous infusion that is nearing completion一位靜脈輸液即將結束的病人
- CA client with diabetes scheduled for a fasting blood glucose test一位預約進行空腹血糖檢測的糖尿病病人
- DA client who is post-operative day 2 and reporting calf tenderness✓ 正解一位術後第二天並主訴小腿壓痛的病人
術後第二天出現小腿壓痛（Calf tenderness）是深層靜脈栓塞（DVT）的潛在徵象，這可能導致致命的肺栓塞。護理原則應優先評估可能引發嚴重併發症的病人。空腹血糖、靜脈輸液更換與轉位協助皆屬常規且預期內的護理需求，其急迫性均低於可能導致急性循環或呼吸損害的栓塞徵兆。
Calf tenderness on the second postoperative day is a potential sign of deep vein thrombosis (DVT), which can lead to a fatal pulmonary embolism. Nursing principles dictate that clients at risk of serious complications be assessed first. Fasting glucose testing, completion of an IV infusion, and assistance with transfer are routine and expected nursing tasks; their urgency is lower than that of a possible embolic event causing acute circulatory or respiratory compromise.
美台護理對於 DVT 的警覺性均極高，評估時需檢查 Homans' sign 或相關臨床指標。