— 降低風險 · HARD · MCQ —
護理師為創傷病人進行初步評估。應遵循何種順序？
A nurse is performing a primary survey on a trauma client. Which order should the nurse follow?
- ABreathing, Airway, Circulation, Disability, Exposure呼吸、呼吸道、循環、失能、暴露
- BAirway, Circulation, Breathing, Exposure, Disability呼吸道、循環、呼吸、暴露、失能
- CCirculation, Airway, Breathing, Exposure, Disability循環、呼吸道、呼吸、暴露、失能
- DAirway, Breathing, Circulation, Disability, Exposure✓ 正解呼吸道、呼吸、循環、失能、暴露
— Explanation · 中文詳解 —
創傷評估的標準流程為 ABCDE：Airway（呼吸道與頸椎保護）、Breathing（呼吸）、Circulation（循環與止血）、Disability（神經學評估）、Exposure（檢查全身防失溫）。這是所有急診護理的核心。
The standard process for trauma assessment is ABCDE: Airway (airway management with cervical spine protection), Breathing, Circulation (including hemorrhage control), Disability (neurological assessment), and Exposure (full-body examination with prevention of hypothermia). This is the core framework for all emergency nursing.
✦ 台美臨床差異
兩地急診與 ICU 皆使用一致的 ABCDE 評估架構，無地域差異。