— 降低風險 · HARD · MCQ —
護理師評估甲狀腺切除術後 4 小時的病人，發現有喉鳴音。護理師首要採取的行動為何？
A nurse is assessing a client who is 4 hours post-thyroidectomy. The nurse notes the client is experiencing laryngeal stridor. What is the nurse's priority action?
- APrepare for emergency tracheostomy✓ 正解準備緊急氣管切開術
- BAdminister IV calcium gluconate靜脈注射葡萄糖酸鈣
- CPlace the client in a semi-Fowler's position將患者置於半坐臥位
- DPerform an assessment of Chvostek's sign評估 Chvostek 徵象
— Explanation · 中文詳解 —
喉鳴音（laryngeal stridor）是呼吸道阻塞的徵兆，對於剛動過甲狀腺手術的病人，這通常由術後水腫或血腫壓迫氣管引起。呼吸道安全為最高優先級（ABC 原則），若出現喘鳴，必須準備氣管切開或插管以維持通暢。
Laryngeal stridor is a sign of airway obstruction; in a client who has just undergone thyroid surgery, this is generally caused by postoperative edema or a hematoma compressing the trachea. Airway safety has the highest priority (ABC principle); when stridor appears, the nurse must prepare for emergency tracheostomy or intubation to maintain patency.
✦ 台美臨床差異
美國護理師在重症或術後單位多具備參與氣管插管協助能力；台灣則高度依賴麻醉科醫師與外科醫師執行插管。