— 降低風險 · MEDIUM · MCQ —
護理師照護一位全層燒傷病人，緊急階段首要措施為何？
A nurse is caring for a client with a full-thickness burn. Which intervention is the priority in the emergent phase?
- AApplying topical antibiotic ointment塗抹局部抗生素藥膏
- BAssessing the extent of the burn評估燒傷範圍
- CMonitoring urine output監測尿液輸出量
- DMaintaining a patent airway✓ 正解維持呼吸道暢通
— Explanation · 中文詳解 —
燒傷病人在緊急期（emergent phase）首要重點是維持 ABC（呼吸、循環、呼吸道）。全層燒傷病人若涉及頭頸部，極易發生吸入性損傷造成水腫阻塞呼吸道，因此首要行動永遠是確保呼吸道通暢（airway）。
In the emergent phase of burn care, ABCs are the priority. Full-thickness burns involving the head/neck readily cause inhalation injury with airway edema and obstruction; thus airway maintenance is always the first action.
✦ 台美臨床差異
兩地皆遵循 ATLS（高級創傷生命支持）原則，燒傷中心護理師在此領域皆需具備高度專業辨識能力。