護理師獲報病人突然胸痛。哪位病人應優先處理？
A patient with a sudden onset of chest pain is reported to the RN. Which patient should the nurse see first?
- AA patient with chronic COPD with a respiratory rate of 22/min一位呼吸頻率為 22 次/分的慢性 COPD 病人
- BA patient waiting for a scheduled dressing change一位等待預定換藥的病人
- CA postoperative patient with new onset of chest pain and dyspnea✓ 正解一位出現新發胸痛與呼吸困難的術後病人
- DA patient with stable angina reporting mild discomfort一位報告輕微不適的稳定型心絞痛病人
在 NCLEX 考試中，處理病人優先順序（Prioritization）的核心原則是 ABC（呼吸、循環、氣道）以及「不穩定 vs. 穩定」。術後病人若突然出現胸痛合併呼吸困難，必須高度懷疑為肺栓塞（Pulmonary Embolism, PE）或心肌缺氧等危及生命的併發症。護理師應優先評估此類病人，以防病情迅速惡化至心跳呼吸停止。其他選項皆屬穩定或慢性病程，優先級較低。
On the NCLEX, the core principles of prioritization are the ABCs (airway, breathing, circulation) and the distinction between unstable and stable clients. A postoperative client who suddenly experiences chest pain together with dyspnea must be highly suspected of having a life-threatening complication such as pulmonary embolism (PE) or myocardial ischemia. The nurse should evaluate this client first to prevent rapid deterioration to cardiopulmonary arrest. The other options describe stable conditions or chronic disease processes and are lower priority.
美國臨床環境中，針對這種急性變化，護理師通常需立即啟動快速反應小組（Rapid Response Team, RRT）或通知醫師，並準備進行心電圖（ECG）檢查及血液氣體分析，流程要求極高的警覺性。