護理師在外科病房同時照顧四位病人，哪一位應優先評估？
A nurse is working on a medical-surgical unit and is assigned four clients. Which client should the nurse assess first?
- AA client with an indwelling catheter who has had no urine output for 2 hours留置導尿管且兩小時內無尿液排出的病人
- BA client admitted with respiratory distress who is now complaining of increased dyspnea✓ 正解因呼吸窘迫入院，現在抱怨呼吸困難加劇的病人
- CA client with a new diagnosis of diabetes mellitus who needs insulin teaching新診斷為糖尿病且需要胰島素衛教的病人
- DA client who is 2 days post-op and reports pain of 6 on a 0-10 scale術後第二天，報告疼痛指數為 6（0-10 分）的病人
根據 ABC 評估原則（氣道、呼吸、循環），呼吸窘迫惡化代表病人狀況有急劇變化，若處理不當可能導致呼吸衰竭，故優先級最高。導尿管尿量異常需進一步觀察但暫無生命危險，術後疼痛與新病患教學皆屬於可安排預計護理計畫的範疇。
According to the ABC framework (Airway, Breathing, Circulation), worsening respiratory distress represents a rapid change in the client's condition and may lead to respiratory failure if not addressed; therefore, it has the highest priority. Abnormal urine output from an indwelling catheter needs further observation but is not immediately life-threatening, and postoperative pain and teaching for a newly admitted client fall within the scope of routine planned care.
美國護理師常利用 Rapid Response Team (RRT) 進行早期介入，台灣多由護理師先回報值班醫師評估。