護理師被分配照顧四位病人。護理師應優先評估哪位病人？
A nurse is assigned to four clients. Which client should the nurse assess first?
- AA client with a chest tube who has 100 mL of serosanguineous drainage in the last hour.一位胸腔引流管病人，過去一小時有 100 mL 漿液血性引流液
- BA client 1 day postoperative after a total knee replacement reporting a pain level of 7 out of 10.一位全膝關節置換術後一天，主觀疼痛程度為 10 分中的 7 分的病人
- CA client with chronic obstructive pulmonary disease (COPD) and an SpO2 of 90% on 2L oxygen.一位慢性阻塞性肺病（COPD）病人，在 2L 氧氣下血氧飽和度（SpO2）為 90%
- DA client with a suspected head injury who was previously alert and is now difficult to arouse.✓ 正解一位疑似頭部外傷病人，先前意識清醒，現在卻難以喚醒
此題的核心在於應用 ABC（呼吸、循環）與神經系統優先順序。病患 D 出現意識狀態改變（從清醒變為難以喚醒），這是神經系統惡化或顱內壓增高的早期且最關鍵徵兆，若不及時介入可能導致腦疝脫或呼吸衰竭，因此必須列為首要優先。病患 A 的胸管引流量 100 mL/hr 在術後早期雖需注意，但 serosanguineous（漿液血性）是預期中的，且 100 mL 是常見的監測門檻，不比意識改變緊急。病患 B 的 SpO2 90% 對於 COPD 病人而言屬於可接受的正常範圍（通常目標為 88-92%）。病患 C 的疼痛雖高，但在術後第一天是可預期的生理反應，不具立即生命威脅。護理師在臨床決策時，必須先識別出「不穩定」且具有「潛在致命性」的徵象，意識狀態的急性改變永遠是紅旗（Red Flag）。
The core of this item is applying the ABC (breathing, circulation) and neurologic priority framework. Client D shows a change in level of consciousness (from alert to difficult to arouse), which is an early and most critical sign of neurologic deterioration or rising intracranial pressure; without timely intervention, brain herniation or respiratory failure may ensue, so this client must be first priority. Client A's chest tube output of 100 mL/hr warrants attention in the early postoperative period, but serosanguineous drainage is expected and 100 mL is a common monitoring threshold, less urgent than a change in level of consciousness. Client B's SpO2 of 90% is within the acceptable range for a COPD client (target typically 88-92%). Client C's pain, although severe, is an expected physiologic response on postoperative day 1 and does not constitute an immediate life threat. In clinical decision-making, the nurse must first identify signs of instability and potential lethality; an acute change in consciousness is always a red flag.
美國 NCLEX 強調神經系統徵象改變的獨立判斷力，護理師需立即啟動 Rapid Response Team (RRT)；台灣臨床則多由護理師先測量生命徵象與 GCS 後，立即通報住院醫師或主治醫師進行處置，流程上對醫師依賴度稍高。