— 降低風險 · HARD · MCQ —
護理師照護一位剛進行甲狀腺切除術的病人，下列哪項發現需要護理師立即關注？
A nurse is caring for a client who has just returned from a thyroidectomy. Which finding requires the nurse's immediate attention?
- ASlight redness at the incision site切口處輕微發紅
- BLaryngeal stridor✓ 正解喉頭喘鳴
- CPatient reports pain at the surgical site個案報告手術部位疼痛
- DDifficulty speaking when answering questions回答問題時說話困難
— Explanation · 中文詳解 —
喉部喘鳴音（Laryngeal stridor）是呼吸道阻塞的徵象，常見於術後血腫壓迫或喉頭水腫，若不及時處理會導致窒息，屬於生命威脅，必須優先處置。其他選項如輕微紅腫或疼痛為術後常見反應，講話困難需觀察有無聲帶損傷，但優先級皆低於維持呼吸道通暢。
Laryngeal stridor indicates airway obstruction, often from postoperative hematoma compression or laryngeal edema. Failure to address it can lead to asphyxiation and is therefore the priority. The other findings (slight redness, surgical pain, hoarseness) are common postoperative responses and are lower priority than airway patency.
✦ 台美臨床差異
美台皆強調術後呼吸道評估，但美國護理師對氣道梗塞的即時評估警覺性教育更為嚴格。