— 照護管理 · EASY · MCQ —
護理師在急診進行檢傷分類，哪位病人應優先評估？
A nurse is triaging clients in the emergency department. Which client should the nurse assess first?
- AA 35-year-old with a minor laceration on the forearm requiring sutures前臂有輕微撕裂傷且需要縫合的 35 歲患者
- BA 60-year-old with sudden onset of substernal chest pressure radiating to the jaw✓ 正解突然出現胸骨下壓迫感並輻射至下巴的 60 歲患者
- CA 40-year-old with a productive cough and a temperature of 38.5°C有產痰性咳嗽且體溫 38.5°C 的 40 歲患者
- DA 25-year-old with a suspected ankle fracture reporting pain of 8/10疑似踝關節骨折並報告疼痛程度為 8/10 的 25 歲患者
— Explanation · 中文詳解 —
根據檢傷分類原則，需優先處理威脅生命的緊急狀況。胸痛是心肌梗塞的典型表現，具高度猝死風險，必須優先評估心電圖與生命徵象以爭取黃金救援時間。骨折、輕微撕裂傷或發燒雖需治療，但尚未達威脅生命等級，可稍後處理。
According to triage principles, life-threatening emergencies must be addressed first. Chest pain is a classic presentation of myocardial infarction and carries a high risk of sudden death; an ECG and vital signs must be obtained promptly to preserve the golden window for intervention. A fracture, a minor laceration, or a fever require treatment but are not immediately life-threatening and can be addressed slightly later.
✦ 台美臨床差異
美台皆遵循 ABC 原則（Airway, Breathing, Circulation），但在急診檢傷系統（如 ESI）分級執行上基本一致。