NurslixJournal
安全與感染控制 · HARD · MCQ

護理師應先去探視哪位病人?

Which client should the nurse visit first?

  • AA client asking for a scheduled oral antibiotic
    要求按時口服抗生素的病人
  • BA client with a new diagnosis of diabetes
    新診斷為糖尿病的病人
  • CA client who needs a dressing change for a chronic wound
    慢性傷口需要換藥的病人
  • DA client complaining of sudden, severe chest pain✓ 正解
    抱怨突然嚴重胸痛的病人
Explanation · 中文詳解

NCLEX 考題的核心在於「優先順序(Prioritization)」。護理師必須依據 ABC(氣道、呼吸、循環)原則及危急性來判斷探視順序。急性胸痛(Chest pain)極可能是急性冠心症候群(ACS)或心肌梗塞(MI),屬於潛在致命、需立即介入的緊急狀況。其他選項如衛教、傷口換藥或例行給藥,雖是護理工作的一部分,但皆非危及生命,可安排在穩定病人處理完畢後執行。

The core of NCLEX questions lies in prioritization. The nurse must determine the order of visits based on the ABC (airway, breathing, circulation) principle and the degree of urgency. Acute chest pain is very likely to represent acute coronary syndrome (ACS) or myocardial infarction (MI), a potentially life-threatening condition that requires immediate intervention. The other options — patient education, chronic wound dressing change, or routine medication administration — are part of nursing care but are not life-threatening and may be addressed after stable clients have been managed.

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