NurslixJournal
安全與感染控制 · MEDIUM · MCQ

護理師需評估多位病人,下列哪位應優先處理?

A nurse is prioritizing care for clients. Which client should the nurse see first?

  • AA client reporting pain at the IV site
    主訴靜脈注射部位疼痛的客戶
  • BA client with a new onset of sudden confusion✓ 正解
    新發突發性意識混亂的客戶
  • CA client with a fever of 100.4 F (38 C)
    體溫 100.4 F (38 C) 的客戶
  • DA client requesting a refill for stool softener
    要求補充軟便劑的客戶
Explanation · 中文詳解

護理師在進行優先順序評估(Prioritization)時,必須遵循ABC原則(Airway, Breathing, Circulation)及「急性重於慢性」的邏輯。新發生的意識混亂(New onset confusion)不僅是急性神經學變化,更常是敗血症(Sepsis)、缺氧、電解質不平衡或低血糖的警訊,這些狀況若未及時介入,可能迅速惡化導致病人生命危險。相較之下,其他選項多屬穩定狀況或非急性威脅。

When performing prioritization, the nurse must follow the ABC principle (Airway, Breathing, Circulation) and the logic that "acute takes precedence over chronic." New-onset confusion is not only an acute neurologic change but is also frequently a warning sign of sepsis, hypoxia, electrolyte imbalance, or hypoglycemia; without timely intervention these conditions can rapidly deteriorate and threaten the patient's life. By comparison, the other options represent stable conditions or non-acute threats.

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