— 生理適應 · HARD · MCQ —
護理師照護一位臉部與胸部燒傷的病人。哪項護理行動最關鍵？
A nurse is caring for a patient with burns on their face and chest. Which nursing action is most critical?
- ACalculate total body surface area burned計算全身體表面積燒傷面積
- BAssess airway patency✓ 正解評估氣道通暢性
- CApply topical antibiotic cream塗抹局部抗生素藥膏
- DEncourage high protein intake鼓勵高蛋白飲食
— Explanation · 中文詳解 —
燒傷病人照護的核心原則為ABC（Airway, Breathing, Circulation）。臉部與胸部燒傷極易合併吸入性損傷（Inhalation injury），導致呼吸道黏膜水腫、發炎與分泌物增加，進而導致氣道阻塞。氣道阻塞是燒傷後最早出現的致命性威脅，因此維持呼吸道通暢（Airway patency）絕對是最高優先級的護理行動。
The guiding principle for burn care is ABC (Airway, Breathing, Circulation). Burns of the face and chest are frequently associated with inhalation injury, which causes airway mucosal edema, inflammation, and increased secretions, leading to airway obstruction. Airway obstruction is the earliest life-threatening complication after a burn, so maintaining airway patency is unquestionably the highest priority nursing action.