— 照護管理 · MEDIUM · SATA —
護理長應優先評估哪幾位病人？（選所有適合的）
Which of the following clients should the charge nurse prioritize for assessment? (Select all that apply.)
- AA client with a sudden onset of confusion post-cardiac catheterization✓ 正解心導管術後突然出現意識混亂的病人
- BA client requesting pain medication for a chronic back condition因慢性背部狀況要求止痛藥的病人
- CA client reporting sudden shortness of breath following a hip replacement✓ 正解髖關節置換術後報告突然呼吸困難的病人
- DA client scheduled for discharge this morning安排今早出院的病人
- EA client with a new onset of unequal pupils after a head injury✓ 正解頭部受傷後新出現瞳孔大小不一的病人
— Explanation · 中文詳解 —
優先順序遵循 ABC 原則（氣道、呼吸、循環）及生命威脅等級。A 涉及神經學變化或栓塞風險，C 疑似肺栓塞，E 顯示腦部壓力變化，三者均為緊急狀況。B 與 D 雖然需要關注，但在急性病況面前屬於常規護理。
Prioritization follows the ABC principle (Airway, Breathing, Circulation) and the level of threat to life. Option A involves a neurologic change or embolic risk, C suggests pulmonary embolism, and E indicates a change in intracranial pressure; all three are emergent situations. Although B and D require attention, they constitute routine care relative to acute clinical deterioration.
✦ 台美臨床差異
台美均採 ABC 原則 triage；美國護理師更強調利用 early warning scores 來篩選優先級。