— 照護管理 · HARD · SATA —
護理師應優先評估下列哪些病人？（選所有適合的）
Which of the following clients should the nurse see first? (Select all that apply.)
- AClient with COPD complaining of difficulty breathing✓ 正解抱怨呼吸困難的慢性阻塞性肺病個案
- BClient post-op day 1 requesting pain medication術後第一天要求止痛藥的個案
- CClient with sudden onset of chest pain and diaphoresis✓ 正解突然出現胸痛並伴隨冒汗的個案
- DClient scheduled for discharge with minor wound dressing change預約出院且僅需更換小型傷口敷料的個案
- EClient with a drop in blood pressure to 80/40 mmHg✓ 正解血壓降至 80/40 mmHg 的個案
— Explanation · 中文詳解 —
護理師需依據 ABC 原則（Airway, Breathing, Circulation）與緊急程度進行 triage（分診）。呼吸困難（COPD）、疑似急性心肌梗塞（胸痛合併冒汗）與休克徵象（低血壓 80/40）均屬於危及生命的情況，需立即處理。止痛需求與出院衛教雖重要，但屬於穩定病患，優先級低於上述急症。
The nurse must triage according to the ABC principle (Airway, Breathing, Circulation) and the level of urgency. Respiratory distress (COPD), suspected acute myocardial infarction (chest pain with diaphoresis), and signs of shock (blood pressure 80/40) are all life-threatening situations that require immediate intervention. Pain medication requests and discharge teaching are important but represent stable clients and rank below these urgent conditions.