一位護理師正在接收入院病人，病人主訴胸痛。哪項初步措施對病人安全最為關鍵？
A nurse is admitting a client with chest pain. Which initial action is most critical for client safety?
- AAdminister a PRN opioid analgesic.給予按需使用的鴉片類鎮痛劑
- BNotify the client's family about the admission.通知病人家屬其已入院
- CObtain a detailed pain history from the client.向病人詳細詢問疼痛病史
- DAssess the client's airway, breathing, and circulation (ABC).✓ 正解評估病人的呼吸道、呼吸與循環（ABC）
護理臨床決策的首要原則是評估優先性（Prioritization）。對於主訴胸痛的病人，必須優先排除致命性心血管事件（如心肌梗塞）。依照 ABC（Airway, Breathing, Circulation）評估架構，護理師必須先確認呼吸道暢通、呼吸模式與循環狀況（血壓、心跳、灌流），確保生命徵象穩定，方可進行下一步的病史收集或給藥。
The foremost principle of nursing clinical decision-making is prioritization. For a client presenting with chest pain, life-threatening cardiovascular events (such as myocardial infarction) must be ruled out first. Following the ABC (Airway, Breathing, Circulation) framework, the nurse must first ensure a patent airway, assess breathing patterns and circulatory status (blood pressure, heart rate, perfusion), and confirm hemodynamic stability before proceeding to history taking or medication administration.