— 降低風險 · HARD · MCQ —
一位病人因胸部及頸部燒傷入院。護理師最優先擔憂的風險為何？
A client is admitted with burns on the chest and neck. What is the nurse's priority concern?
- AAirway obstruction✓ 正解呼吸道阻塞
- BInfection risk感染風險
- CFluid volume deficit體液容量不足
- DPain management疼痛控制
— Explanation · 中文詳解 —
在燒傷病人的急救評估中，ABC（Airway, Breathing, Circulation）原則永遠是核心。胸部及頸部燒傷因靠近呼吸道入口，極易引發喉頭水腫（Laryngeal edema）與呼吸道阻塞，即便病人入院時呼吸平順，也可能在數小時內迅速惡化。因此，優先保障呼吸道通暢（維護氣道安全）是挽救生命的最優先行動，護理師應準備氣管插管設備以防不測。
In burn assessment, the ABCs (Airway, Breathing, Circulation) always come first. Chest and neck burns are near the airway and can rapidly cause laryngeal edema and obstruction, even if breathing initially appears stable. Maintaining airway patency is the top priority, and intubation equipment should be at the bedside.