— 降低風險 · HARD · MCQ —
護理師在甲狀腺切除術後 4 小時評估病人。哪個發現最令人擔憂？
A nurse is assessing a client 4 hours post-thyroidectomy. Which assessment finding is the most concerning?
- ADifficulty swallowing吞嚥困難
- BHoarseness when speaking說話時聲音沙啞
- CIncision site pain切口部位疼痛
- DStridor during inspiration✓ 正解吸氣時出現喘鳴聲
— Explanation · 中文詳解 —
甲狀腺切除術後，病人面臨氣道阻塞的風險。吸氣性喘鳴（Stridor）屬於高音調的呼吸音，反映了上呼吸道因水腫、出血或聲帶麻痺而嚴重狹窄。這是危及生命的緊急狀況，必須優先處理以確保氣道通暢。護理思路應遵循 ABC（Airway, Breathing, Circulation）原則，呼吸道受阻是第一優先級別。
After thyroidectomy, the client faces airway obstruction risk. Inspiratory stridor is a high-pitched breath sound reflecting severe upper airway narrowing from edema, bleeding, or vocal cord paralysis. This is a life-threatening emergency requiring immediate intervention to ensure airway patency. Nursing thinking follows ABC priorities—airway obstruction is the first priority.
✦ 台美臨床差異
在美國臨床，護理師一旦聽到喘鳴，會立即啟動 Rapid Response Team (RRT) 並準備床邊氣管切開包 (Tracheostomy tray)，因為美國醫療法規極度強調術後氣道維護的即時性。