— 照護管理 · EASY · MCQ —
護理師在急診進行檢傷分類，哪一位病人應優先照護？
A nurse is triaging clients in an emergency department. Which client should the nurse see first?
- AA client with a closed ankle fracture reporting pain of 8/10主訴疼痛 8/10 的閉合性踝關節骨折病人
- BA client with a fever of 101.2°F and a productive cough體溫 101.2°F 且有產痰性咳嗽的病人
- CA client with a laceration on the forearm requiring sutures前臂有裂傷需要縫合的病人
- DA client reporting sudden onset of substernal chest pain and diaphoresis✓ 正解主訴突然發作胸骨下疼痛且冒冷汗的病人
— Explanation · 中文詳解 —
急診檢傷分類遵循優先處理威脅生命狀況的原則。胸痛伴隨冒冷汗是急性心肌梗塞的典型症狀，屬於立即威脅生命的優先級，必須立刻處置以減少心肌壞死。骨折、撕裂傷及發燒雖需治療，但相較於急性冠狀動脈症候群，其穩定度較高，屬於非危及生命的次要緊急程度。
Emergency department triage follows the principle of addressing life-threatening conditions first. Chest pain accompanied by diaphoresis is a typical sign of acute myocardial infarction and represents an immediate life-threatening priority that must be addressed at once to limit myocardial necrosis. Fractures, lacerations, and fever require treatment, but compared with acute coronary syndrome they are more stable and constitute lower-priority, non-life-threatening urgency.
✦ 台美臨床差異
台美在檢傷系統（如 TTS 或 ESI）使用邏輯相似，均以生命徵象與潛在致命風險作為首要考量。