護理師需評估內外科病房病人的照護優先順序，應先探視哪位病人？
A nurse is prioritizing care for clients on a medical-surgical unit. Which client should the nurse see first?
- AA client who is 2 days post-op and reporting pain level of 4/10一位術後第2天並報告疼痛程度為4/10的病人
- BA client with heart failure who is reporting 2+ pitting edema in the ankles一位有心衰竭病史並報告踝部有2+凹陷性水腫的病人
- CA client with chronic obstructive pulmonary disease who has an oxygen saturation of 89% on 2L NC一位患有慢性阻塞性肺病且在2L鼻導管下氧飽和度為89%的病人
- DA client who is post-op following a thyroidectomy and has developed stridor✓ 正解一位甲狀腺切除術後並出現喘鳴聲的病人
運用 ABC（呼吸、呼吸道、循環）評估原則。甲狀腺切除術後出現「喘鳴音（Stridor）」是呼吸道阻塞的徵兆，隨時可能導致氣道完全封閉與窒息，屬於危急情境。B、A、C 的狀況均為慢性或預期內的術後反應，優先順序低於呼吸道阻塞。此病人需立即評估並通知外科醫師準備緊急插管或氣切。
Apply the ABC assessment principle (Airway, Breathing, Circulation). Stridor occurring after thyroidectomy is a sign of airway obstruction that may at any moment lead to complete airway closure and asphyxiation, constituting an emergent situation. The conditions described in options B, A, and C are chronic or expected postoperative findings and rank below airway obstruction in priority. This client requires immediate assessment and notification of the surgeon to prepare for emergency intubation or tracheostomy.
美國護理師對術後併發症識別訓練極強；台灣護理師常因工作量過大，對此類術後細微變化警覺性需提升。