— 降低風險 · HARD · MCQ —
護理師照護一位甲狀腺切除術後 2 小時的病人，發現病人出現喘鳴（stridor）。護理師應優先採取何種行動？
A nurse is caring for a client who is 2 hours post-operative after a thyroidectomy. The nurse notes the client is experiencing stridor. Which action is the priority?
- AElevate the head of the bed to 45 degrees將床頭抬高至 45 度
- BAdminister IV corticosteroids給予靜脈注射皮質類固醇
- CCall the Rapid Response Team✓ 正解呼叫快速反應小組
- DCheck the surgical dressing for bleeding檢查手術敷料是否有出血
— Explanation · 中文詳解 —
甲狀腺切除術後出現喘鳴，暗示可能發生喉頭水腫或血腫壓迫氣道，屬於氣道阻塞的緊急徵兆。若不及時處理將導致窒息。啟動快速反應小組（RRT）能立即取得插管設備與氣道管理資源，這是確保病人存活的首要關鍵步驟。
Stridor following thyroidectomy suggests possible laryngeal edema or a hematoma compressing the airway, which is an emergency sign of airway obstruction. Without prompt management, asphyxiation may occur. Activating the Rapid Response Team (RRT) immediately mobilizes intubation equipment and advanced airway-management resources, and is the most critical first step in ensuring client survival.
✦ 台美臨床差異
美方醫院 RRT 流程明確，護理師職權較大可直接召喚；台灣醫院通常依據各院 SOP 呼叫 Code Blue 或醫師，護理師自主啟動的授權範圍較為受限。