內外科病房護理師剛交接完四位病人。護理師應優先評估哪位病人？
A nurse on a medical-surgical unit is receiving a report on four clients. Which client should the nurse assess first?
- AA client with pneumonia who has a pulse oximetry reading of 91% on room air一位肺炎病人，在呼吸空氣下脈搏血氧濃度讀數為 91%
- BA client with diabetes whose pre-meal blood glucose is 150 mg/dL一位糖尿病病人，餐前血糖為 150 mg/dL
- CA client with a deep vein thrombosis reporting sudden shortness of breath✓ 正解一位深層靜脈血栓形成病人，主訴突然呼吸困難
- DA client 2 days postoperative who reports pain as 7 on a scale of 0 to 10一位術後兩天的病人，報告疼痛程度為 0 到 10 分中的 7 分
優先排序的黃金準則通常遵循 ABC（Airway 呼吸道、Breathing 呼吸、Circulation 循環）原則。在此情境中，患有深層靜脈栓塞（DVT）的病人突然出現呼吸困難，極度懷疑是發生了肺栓塞（Pulmonary Embolism），這是一種威脅生命的急症，必須立即介入。與其他選項相比，A 選項的肺炎病人 SpO2 91% 雖然偏低但尚屬可預期範圍；D 選項的術後疼痛需要處理但非立即致命；B 選項的血糖升高屬於慢性管理範疇。護理師必須能夠識別出哪種情況代表病人生理狀態正急劇惡化，並採取最迅速的行動來挽救生命。
The golden rule of prioritization generally follows the ABCs (Airway, Breathing, Circulation). In this scenario, a client with deep vein thrombosis (DVT) who suddenly develops shortness of breath is highly suspected to be experiencing a pulmonary embolism, a life-threatening emergency that requires immediate intervention. Compared with the other options, the client in option A with pneumonia has SpO2 of 91%, which, although low, is within the expected range; the postoperative pain in option D requires management but is not immediately fatal; the elevated blood glucose in option B falls under chronic management. The nurse must be able to recognize which situation represents an acutely deteriorating physiologic state and take the most rapid action to save the client's life.
美國 NCLEX 非常強調護理師的獨立判斷與優先次序（Prioritization），認為這是確保安全的核心能力；台灣臨床教育中，護理師在遇到此類緊急狀況時，通常被要求第一時間同步通知醫師，雖然兩地處置原則一致，但美國考題更強調護理師在通知前應先進行的關鍵初步評估。