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照護管理 · HARD · MCQ

護理師正在照顧多位病人。下列哪位病人應優先護理?

A nurse is managing the care of multiple clients. Which client should the nurse see first?

  • AA client with a scheduled dressing change for a surgical incision
    一位外科切口scheduled換藥的病人
  • BA client with type 1 diabetes requesting a snack
    一位第一型糖尿病要求點心的病人
  • CA client with chronic hypertension requesting an update on test results
    一位慢性高血壓要求更新檢驗結果的病人
  • DA client with COPD reporting a sudden increase in dyspnea✓ 正解
    一位慢性阻塞性肺病報告呼吸困難突然加劇的病人
Explanation · 中文詳解

護理師優先級排序遵循 ABC 原則(Airway, Breathing, Circulation)。COPD 病人出現呼吸困難加劇(Sudden increase in dyspnea),可能暗示急性呼吸衰竭、氣胸或肺栓塞等生命威脅,必須優先評估與處理。其他選項如糖尿病病人要點心、常規傷口換藥、詢問檢驗結果,雖是照護內容,但皆不具備生命威脅性,屬於可後續安排的任務。

Nursing prioritization follows the ABC principle (Airway, Breathing, Circulation). A COPD client with a sudden increase in dyspnea may be experiencing life-threatening events such as acute respiratory failure, pneumothorax, or pulmonary embolism, and must be assessed and managed first. The other options, such as a diabetic client requesting a snack, a scheduled dressing change, or a request for test results, are appropriate components of care but do not pose immediate threats to life and can be addressed later.

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