— 照護管理 · HARD · SATA —
護理師照護一群外科病人，哪幾位需優先評估？（選所有適合的）
A nurse is caring for a group of clients on a medical-surgical unit. Which client should the nurse see first? (Select all that apply.)
- AA client 2 hours post-op from a hip arthroplasty with an oxygen saturation of 91%✓ 正解髖關節置換術後2小時，血氧飽和度為91%的病人
- BA client with a new diagnosis of diabetes mellitus waiting for discharge teaching新診斷糖尿病，等待出院衛教的病人
- CA client complaining of sudden, severe chest pain and radiating pain to the jaw✓ 正解主訴突然嚴重胸痛並輻射至下巴的病人
- DA client with an indwelling catheter who has had 50 mL of urine output in the last 4 hours✓ 正解留置導尿管，過去4小時尿量僅50 mL的病人
- EA client reporting mild nausea after taking an antibiotic服用抗生素後報告輕微噁心的病人
— Explanation · 中文詳解 —
優先評估順序為：(C) 心絞痛徵兆，可能發生心肌梗塞，危及生命；(A) 術後氧飽和度偏低（<92%），可能有呼吸抑制或術後肺部併發症；(D) 少尿（<30 mL/hr），可能導致腎損傷或脫水。B 為非緊急教育，E 為常見副作用，皆排在後面。
The priority order is as follows: (C) signs of angina, which may indicate impending myocardial infarction and are life-threatening; (A) low postoperative oxygen saturation (<92%), which may indicate respiratory depression or postoperative pulmonary complications; (D) oliguria (<30 mL/hr), which may lead to renal injury or dehydration. B is non-urgent teaching and E is a common side effect, both of which can be addressed afterward.
✦ 台美臨床差異
在急重症單位，這些評估順序均為標準化流程，台美護理教育皆強調此類臨床判斷邏輯。