— 照護管理 · MEDIUM · MCQ —
下列哪位病人應優先護理評估？
Which of the following clients should the nurse prioritize to see first?
- AA client waiting for discharge education等待出院衛教的病患
- BA client with a scheduled dressing change預約更換敷料的病患
- CA client complaining of sudden onset chest pain✓ 正解主訴突發性胸痛的病患
- DA client with a minor cough有輕微咳嗽的病患
— Explanation · 中文詳解 —
根據 ABC（Airway, Breathing, Circulation）原則，心臟相關的不適（胸痛）可能暗示心肌缺血或梗塞，是緊急狀況。B、A、D 皆屬於非緊急之護理範疇。優先順序應採取緊急性最高之案例進行評估。
According to the ABC (Airway, Breathing, Circulation) principle, cardiac-related complaints such as chest pain may indicate myocardial ischemia or infarction and constitute an emergency. Options B, A, and D fall within non-urgent nursing care. The priority order should focus on assessing the case with the highest acuity first.
✦ 台美臨床差異
台美皆遵循 triage 原則，但在結構化評估工具的使用上（如 ESI）美國更為普及。