— 照護管理 · EASY · MCQ —
護理師需評估內外科病房的四位病人，哪位應最優先查看？
A nurse is prioritizing care for four clients on a medical-surgical unit. Which client should the nurse see first?
- AA client requesting pain medication for a rated 4/10 postoperative incision pain主訴術後切口疼痛評分為4/10，要求止痛藥的病人
- BA client waiting for discharge instructions following an appendectomy接受闌尾切除術後等待出院衛教的病人
- CA client with a newly diagnosed DVT reporting sudden sharp chest pain and dyspnea✓ 正解新診斷為深層靜脈血栓形成（DVT），報告突然劇烈胸痛和呼吸困難的病人
- DA client with type 2 diabetes who has a blood glucose level of 140 mg/dL第二型糖尿病且血糖值為140 mg/dL的病人
— Explanation · 中文詳解 —
護理師在處理多位病人時，必須依據 ABC（呼吸、呼吸道、循環）原則進行優先順序評估。該名 DVT 病人出現突然的胸痛和呼吸困難，強烈暗示發生了肺栓塞（PE），這是危及生命的緊急狀況，必須立即處理，否則病人會有休克風險。
When managing multiple clients, the nurse must prioritize using the ABC (airway, breathing, circulation) principles. This client with DVT presenting with sudden chest pain and dyspnea is highly suggestive of pulmonary embolism (PE), a life-threatening emergency that must be managed immediately or the client may go into shock.
✦ 台美臨床差異
美台兩地護理原則皆遵循 ABC 優先級，但台灣護理師在確認 PE 後通常需更積極啟動急救團隊（如 Code Blue/Rapid Response）。