— 照護管理 · HARD · SATA —
護理師應優先照護下列哪些病人？（選所有適合的）
Which clients should the nurse prioritize to see first? (Select all that apply.)
- AA client with a new onset of sudden confusion and unequal pupils✓ 正解新發突然意識混亂且瞳孔大小不一的病人
- BA client with stage 2 pressure ulcer requiring a dressing change需要換藥的二級壓瘡病人
- CA client reporting severe chest pain and diaphoresis✓ 正解主訴嚴重胸痛和冒冷汗的病人
- DA client with a hemoglobin level of 10.5 g/dL needing iron supplementation血色素為 10.5 g/dL 且需要補充鐵劑的病人
- EA client experiencing active airway obstruction or respiratory distress✓ 正解經歷活動性呼吸道阻塞或呼吸窘迫的病人
— Explanation · 中文詳解 —
依據 ABC（Airway, Breathing, Circulation）原則與生命危急度排序。A、C、E 皆涉及生命中樞神經、心血管與呼吸系統的危急徵象，需立即介入。B 與 D 雖然重要，但病情穩定，屬於慢性問題，可排在急救處置之後進行處理。
Prioritize by ABCs (airway, breathing, circulation) and life-threat. A, C, and E all involve acute central nervous, cardiovascular, or respiratory emergencies requiring immediate action. B and D are important but stable — chronic issues that can wait.
✦ 台美臨床差異
台美護理師皆接受過 ABC triage 訓練，但在急診或病房評估時，美方更強調即刻啟動 Rapid Response Team。