一位護理師正在管理多位病人。應優先評估哪位病人？
A nurse is managing care for multiple clients. Which client should the nurse assess first?
- AA client with stable vital signs and a scheduled medication.生命徵象穩定且有預定給藥的病人
- BA client waiting for discharge instructions after a routine procedure.常規手術後等待出院指導的病人
- CA client who received pain medication 1 hour ago and reports mild discomfort.一小時前接受止痛藥並報告輕微不適的病人
- DA client experiencing sudden shortness of breath and chest pain.✓ 正解出現突發呼吸困難和胸痛的病人
依據 ABC（Airway, Breathing, Circulation）與優先級別原則（Priority Framework），護理師需優先處理危及生命的狀況。突發性呼吸困難與胸痛是急性心肌梗塞（MI）或肺栓塞（PE）的潛在徵兆，這屬於呼吸與循環系統的不穩定，若不及時介入，病人可能會迅速惡化至心跳停止。其他選項皆為穩定狀態的病人，應列於優先評估之後。
Based on the ABC (Airway, Breathing, Circulation) principle and priority framework, the nurse must first address life-threatening conditions. Sudden shortness of breath and chest pain are potential signs of acute myocardial infarction (MI) or pulmonary embolism (PE), representing instability in the respiratory and circulatory systems; without prompt intervention the patient could rapidly deteriorate to cardiac arrest. The other clients are stable and should be assessed afterward.