— 照護管理 · EASY · MCQ —
護理師需評估四位病人，哪一位應優先處理？
A nurse is prioritizing care for four clients. Which client should the nurse see first?
- AA client with COPD who has a new onset of audible wheezing and restlessness✓ 正解COPD 病患出現新發的可聞性哮鳴音與煩躁不安
- BA client with type 2 diabetes reporting a fasting blood glucose of 140 mg/dL第二型糖尿病病患報告空腹血糖為 140 mg/dL
- CA client with a peripherally inserted central catheter (PICC) dressing due for a changePICC 敷料到期需更換的病患
- DA client 24 hours post-appendectomy reporting moderate incisional pain闌尾切除術後 24 小時報告中度切口疼痛的病患
— Explanation · 中文詳解 —
護理評估應使用 ABC（呼吸、循環、氣道）原則。COPD 病人的哮鳴音與煩躁不安是急性呼吸窘迫的警訊，代表氣道阻塞或缺氧加劇，必須立即介入以維護通氣。其餘選項分別為慢性代謝控制、術後預期疼痛與常規護理，優先級較低。
Nursing assessment should follow the ABC (airway, breathing, circulation) principle. Wheezing and restlessness in a COPD patient are warning signs of acute respiratory distress, indicating airway obstruction or worsening hypoxia, and require immediate intervention to maintain ventilation. The other options represent chronic metabolic control, expected postoperative pain, and routine care, and have a lower priority.
✦ 台美臨床差異
台美兩地皆以臨床嚴重度（Triage）為優先順序，急性呼吸問題皆為第一優先。