護理師被分配照顧四名病人。護理師應優先評估哪位病人？
A nurse is assigned to care for four clients. Which client should the nurse assess first?
- AA client with a history of heart failure who has 2+ pitting edema in the lower extremities.有心衰竭病史且下肢有 2+ 凹陷性水腫的病人。
- BA client with chronic obstructive pulmonary disease (COPD) whose SpO2 is 90% on room air.慢性阻塞性肺病（COPD）病人，其呼吸空氣下的血氧飽和度（SpO2）為 90%。
- CA client with pneumonia who has become increasingly restless and confused over the last hour.✓ 正解肺炎病人，過去一小時內變得越來越躁動與困惑。
- DA client who underwent an appendectomy 12 hours ago and reports pain as 4 on a scale of 10.12 小時前接受闌尾切除術，主訴疼痛指數為 10 分中的 4 分的病人。
本題的核心概念是優先順序判斷（Prioritization），特別是意識狀態改變（Mental Status Change）在 ABC 原則中的重要性。在護理臨床判斷中，急劇的意識改變（躁動、混亂）通常是缺氧、低血糖或敗血症的早期徵兆，屬於生理上的不穩定狀態，必須最先處理。相較之下，心衰竭的肢體水腫（A）是預期中的慢性表現；術後輕微疼痛（D）雖然需要處理，但無生命危險；COPD 病人的 SpO2 90%（B）在該疾病群體中屬於可接受的範圍。護理師應先評估 C 病人以排除生命威脅。安全優先原則要求護理師區分「預期性發現」與「非預期性/急性惡化」。
The core concept of this item is prioritization, particularly the importance of changes in mental status within the ABC framework. In clinical nursing judgment, an acute change in level of consciousness (restlessness, confusion) is often an early sign of hypoxia, hypoglycemia, or sepsis and represents physiologic instability that must be addressed first. By comparison, lower-extremity edema in heart failure (A) is an expected chronic finding; mild postoperative pain (D) needs attention but is not life-threatening; and an SpO2 of 90% in a COPD client (B) is within the acceptable range for that disease group. The nurse should assess client C first to rule out life-threatening causes. The safety principle requires the nurse to differentiate "expected findings" from "unexpected/acute deterioration."
在美國 NCLEX 考題中，意識改變被視為「不穩定」的最高指標之一。在台灣臨床環境，護理師通常也會優先查看此類病人，但有時會受限於醫師巡房順序或家屬呼叫的頻率。NCLEX 強調的是根據生理指標獨立判斷優先順序，而非依據行政便利。