— 照護管理 · MEDIUM · MCQ —
護理師在交班後，應優先評估哪位病人？
Which client should the nurse assess first after receiving the change-of-shift report?
- AA client with diabetes whose morning blood glucose is 140 mg/dL一位早晨血糖為 140 mg/dL 的糖尿病病人
- BA client with a history of heart failure reporting slight ankle edema一位有心衰竭病史並報告輕微踝部水腫的病人
- CA client with asthma who has new onset of wheezing and restlessness✓ 正解一位新發喘息和煩躁不安的哮喘病人
- DA client with chronic renal failure and a creatinine level of 2.8 mg/dL一位肌酸酐水平為 2.8 mg/dL 的慢性腎衰竭病人
— Explanation · 中文詳解 —
此題考驗優先順序判斷，核心原則是 ABCs (Airway, Breathing, Circulation) 以及急性（Acute）優於慢性（Chronic）。氣喘病人出現新的喘鳴音（Wheezing）與躁動不安（Restlessness），是呼吸道受阻與缺氧的早期徵象，屬於醫療急症，必須立即評估並介入。相較之下，慢性腎衰竭的肌酸酐 2.8 mg/dL 對腎衰竭病人屬預期內、糖尿病晨間血糖 140 mg/dL 僅輕微偏高、心衰竭病人出現輕微踝部水腫屬於慢性穩定表現，皆不具立即生命威脅。
The client with asthma exhibiting new wheezing and restlessness requires immediate assessment due to signs of potential respiratory distress and hypoxia. According to the ABC priority framework, airway and breathing issues take precedence over stable chronic conditions or mild abnormalities.
✦ 台美臨床差異
美國 NCLEX 考題極度強調『新發作』或『改變』的症狀。台灣護理實務中，對於 INR 的判斷通常由醫師處理，但護理師必須熟悉此數值以判斷用藥安全性。