一位急性胰臟炎病患主訴嚴重上腹痛。下列護理評估何者最優先？
A client with acute pancreatitis reports severe epigastric pain. Which nursing assessment is the highest priority?
- AAssessing skin turgor評估皮膚張力
- BEvaluating urine output評估尿液排出量
- CChecking bowel sounds檢查腸鳴音
- DMonitoring respiratory status✓ 正解監測呼吸狀態
急性胰臟炎 (Acute pancreatitis) 因嚴重的發炎反應與腹痛，極易引起橫膈膜受限、肺部積液或呼吸淺快，進而導致氣體交換障礙。根據 ABC 原則（Airway, Breathing, Circulation），呼吸狀態是維持生命徵象的優先關鍵。其他選項雖為重要評估項目，但若病人發生呼吸衰竭或缺氧，將立即危及生命，故優先級最高。
Acute pancreatitis, because of severe inflammation and abdominal pain, readily causes diaphragmatic restriction, pleural effusion, or shallow and rapid breathing, leading to impaired gas exchange. According to the ABC principle (Airway, Breathing, Circulation), respiratory status is the priority for sustaining vital signs. Although the other options are important assessment items, if the patient develops respiratory failure or hypoxia, life is immediately endangered, so respiratory status is the highest priority.