內外科病房的護理師正在檢視今日的病人分配。護理師應優先評估哪位病人？
The nurse on a medical-surgical unit is reviewing the client assignments for the day. Which client should the nurse assess first?
- AA client with a history of heart failure who gained 1 lb (0.45 kg) since yesterday.有心衰竭病史，自昨天以來體重增加 1 磅（0.45 公斤）的病人。
- BA client who is 12 hours post-abdominal surgery with no bowel sounds present.腹部手術後 12 小時且無腸蠕動音的病人。
- CA client who had a stroke 3 days ago and is reporting difficulty swallowing water.✓ 正解三天前中風且主訴喝水有吞嚥困難的病人。
- DA client with type 2 diabetes whose pre-breakfast blood glucose is 140 mg/dL.早餐前血糖為 140 mg/dL 的第二型糖尿病病人。
優先順序評估題必須依賴 ABC（Airway, Breathing, Circulation）原則與急迫性（Acute vs Chronic）。選項 C 的病人出現吞嚥困難（Dysphagia），這直接威脅到呼吸道安全（Airway），有極高的風險引發吸入性肺炎，屬於必須立即介入的急性變化。選項 A 的體重增加 1 磅雖需關注，但尚未達到心衰竭失代償的緊急標準（通常 24 小時內 >2 磅才需即時通報）。選項 D 的血糖 140 mg/dL 雖略高但相對穩定。選項 B 術後 12 小時無腸音是預期中的發現（麻醉影響），不具急迫性。因此，保護病人的呼吸道安全是所有臨床情境中的最高優先。
Prioritization questions must be answered using the ABC (Airway, Breathing, Circulation) framework and the principle of acute versus chronic acuity. The client in Option C has dysphagia, which directly threatens airway safety and carries a very high risk of aspiration pneumonia -- an acute change that requires immediate intervention. The 1-lb weight gain in Option A warrants attention but does not meet the threshold for acute decompensation in heart failure (typically >2 lb within 24 hours requires immediate notification). The blood glucose of 140 mg/dL in Option D is slightly elevated but relatively stable. In Option B, the absence of bowel sounds 12 hours after surgery is an expected finding (related to anesthesia) and is not urgent. Protecting the client's airway is therefore the highest priority in any clinical scenario.
美國 NCLEX 考題非常強調「預期與非預期」（Expected vs Unexpected）的區分。台灣臨床護理師有時會受限於病人或家屬的抱怨程度（例如血糖高會被吵）而影響優先順序，但考試必須嚴格遵循生理穩定度與 ABC 原則。