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照護管理 · EASY · MCQ

護理師在內外科病房進行優先級排序,哪位病人應優先處理?

A nurse is working on a medical-surgical unit and is prioritizing patient care. Which client should the nurse see first?

  • AA client with a new onset of sudden confusion✓ 正解
    新發突然意識混亂的病人
  • BA client asking for help with ambulation to the bathroom
    請求協助步行至洗手間的病人
  • CA client with type 2 diabetes requesting a meal tray
    要求用餐盤的第二型糖尿病病人
  • DA client with a scheduled dressing change for a surgical incision
    預約進行手術切口敷料更換的病人
Explanation · 中文詳解

護理優先級排序應遵循 ABC 原則(Airway, Breathing, Circulation)與「急性優先於慢性」原則。突然意識混亂(New onset confusion)是神經學功能改變的警訊,可能代表腦部缺氧、敗血症、代謝性腦病變或電解質紊亂,屬於急性高風險狀況,必須優先評估與處理。其他選項皆屬於常規照護,不具有立即生命威脅。

Nursing prioritization should follow the ABC principle (Airway, Breathing, Circulation) and the rule that 'acute takes precedence over chronic.' New onset of sudden confusion is a warning sign of altered neurological function and may indicate cerebral hypoxia, sepsis, metabolic encephalopathy, or electrolyte derangement; it is an acute high-risk situation that must be assessed and managed first. The other options are routine care and do not pose immediate threats to life.

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