— 降低風險 · HARD · MCQ —
護理師對甲狀腺切除術後病人進行評估，聽見喉鳴音（stridor）。護理師應優先採取何種措施？
A nurse is performing a postoperative assessment on a client who had a thyroidectomy. The nurse notes laryngeal stridor. Which action is the priority?
- ANotify the anesthesiologist to prepare for emergency intubation✓ 正解通知麻醉醫師準備緊急插管
- BCheck the client's vital signs檢查客戶的生命徵象
- CElevate the head of the bed抬高床頭
- DAdminister calcium gluconate給予葡萄糖酸鈣
— Explanation · 中文詳解 —
甲狀腺切除術後出現喉鳴音，通常暗示喉頭水腫或喉返神經損傷導致呼吸道阻塞。這是一個危急情況（Life-threatening），優先順序應放在確保呼吸道通暢，必須立即通知麻醉科或外科醫師準備插管，因為呼吸道隨時可能完全關閉。
Laryngeal stridor following thyroidectomy usually indicates laryngeal edema or recurrent laryngeal nerve injury causing airway obstruction. This is a life-threatening condition; priority should be placed on securing airway patency, and anesthesia or surgery must be notified immediately to prepare for intubation, because the airway may completely close at any moment.
✦ 台美臨床差異
美國醫院有 Rapid Response Team (RRT) 機制，台灣通常直接呼叫住院醫師或啟動緊急醫療小組。