— 照護管理 · MEDIUM · MCQ —
護理長正在分配單位工作。在接班報告後，哪位病人應優先處理？
A charge nurse is managing the unit workflow. Which client should the nurse see first upon receiving the shift report?
- AA client with heart failure complaining of 2+ pitting edema一位有心衰竭並抱怨有 2+ 凹陷性水腫的病人
- BA client with diabetes scheduled for a blood glucose check before lunch一位午餐前安排測量血糖的糖尿病病人
- CA client with pneumonia reporting an oral temperature of 101.2°F (38.4°C)一位主訴口腔溫度為 101.2°F (38.4°C) 的肺炎病人
- DA client with a chest tube showing continuous bubbling in the water seal chamber✓ 正解一位水封瓶內有連續氣泡的胸管病人
— Explanation · 中文詳解 —
護理師需依據 ABC 原則（呼吸、循環、氣道）進行優先排序。持續性氣泡表示胸管系統可能有氣胸或系統漏氣，直接危及呼吸功能，需立即評估。心衰竭水腫與肺炎發燒雖需注意，但並非立即威脅生命之徵象；血糖檢測則屬常規排程護理。
The nurse should prioritize using the ABC framework (airway, breathing, circulation). Continuous bubbling indicates a possible pneumothorax or system leak in the chest tube setup, directly threatening respiratory function and requiring immediate assessment. Heart failure edema and pneumonia-related fever require attention but are not immediately life-threatening, and blood glucose testing is a routine scheduled task.
✦ 台美臨床差異
美國護理師對胸管異常有明確的緊急處理權限；台灣護理師通常需同時通知醫師並進行初步評估。