— 降低風險 · HARD · MCQ —
一位病人甲狀腺切除術後 2 小時，突然出現喘鳴（stridor）與躁動。護理師應優先採取何種行動？
A nurse is caring for a client who is 2 hours postoperative following a thyroidectomy. The client suddenly develops stridor and restlessness. Which action is the priority?
- ACall the rapid response team or surgeon immediately✓ 正解立即呼叫快速反應小組或外科醫師
- BAdminister an analgesic for pain給予止痛藥以緩解疼痛
- CPlace the client in a high-Fowler's position將病人置於高福勒氏臥位
- DCheck the surgical dressing for bleeding檢查手術敷料是否有出血
— Explanation · 中文詳解 —
甲狀腺切除術後，喘鳴（Stridor）是呼吸道阻塞的警訊，通常由喉頭水腫、氣管壓迫（血腫）或喉返神經受損引起。此為 ABC（Airway, Breathing, Circulation）原則中的 Airway 緊急狀況，必須立即呼叫 Rapid Response Team，準備進行氣管插管或氣切，以防窒息。
After thyroidectomy, stridor is a warning sign of airway obstruction, generally caused by laryngeal edema, tracheal compression (hematoma), or recurrent laryngeal nerve injury. This is an airway emergency under ABC (Airway, Breathing, Circulation) principles; the Rapid Response Team must be called immediately to prepare for intubation or tracheostomy to prevent suffocation.