護理師正在協調四位病人的照護。哪位病人應優先評估？
A nurse is coordinating care for four clients. Which client should the nurse assess first?
- AA client 2 days postoperative who reports localized incisional pain一名術後第2天並主訴局部切口疼痛的病人
- BA client with chronic heart failure who has new-onset confusion✓ 正解一名慢性心力衰竭且出現新發意識混亂的病人
- CA client with type 2 diabetes who has a fasting blood glucose of 140 mg/dL一名空腹血糖為 140 mg/dL 的第二型糖尿病病人
- DA client with a superficial pressure injury on the heel一名腳跟有淺層壓瘡的病人
護理優先順序（Prioritization）的基本原則是 ABC（Airway, Breathing, Circulation）。在面對多位病人時，護理師必須評估誰的狀況最不穩定且最可能威脅生命。意識狀態的改變（Confusion）是腦部灌流不足或代謝失衡的早期徵兆，對於心衰竭病人而言，這可能預示著急性缺氧或心輸出量下降，屬於最優先需要評估的對象。
The fundamental principle of nursing prioritization is ABC (Airway, Breathing, Circulation). When managing multiple clients, the nurse must determine who is most unstable and most likely to be in a life-threatening condition. A change in level of consciousness (confusion) is an early sign of impaired cerebral perfusion or metabolic disturbance, and in a client with heart failure may foreshadow acute hypoxia or decreased cardiac output—making this client the highest priority for assessment.