— 降低風險 · MEDIUM · MCQ —
護理師照護一位剛完成甲狀腺切除術的病人。下列哪項評估發現需立即回報醫師？
A nurse is caring for a client who has just returned from a thyroidectomy. Which assessment finding should the nurse report to the provider immediately?
- AHeart rate of 88 beats per minute心率每分鐘 88 次
- BIncisional pain rated as 4 out of 10切口疼痛評分為 4/10
- CNoisy, high-pitched respirations✓ 正解呼吸聲嘈雜且高音調
- DMild hoarseness when speaking說話時輕微聲音沙啞
— Explanation · 中文詳解 —
高頻呼吸聲（Stridor，喘鳴）是喉頭水腫或神經損傷的跡象，恐導致急性呼吸道阻塞。此為術後緊急紅旗，需隨時準備氣道緊急處置工具。輕微沙啞通常因插管引起，心跳與輕度疼痛均在術後預期範圍內，不具立即致命風險。
High-pitched respirations (stridor) are a sign of laryngeal edema or nerve injury and can lead to acute airway obstruction. This is a postoperative red flag that requires emergency airway management equipment to be available at all times. Mild hoarseness is usually due to endotracheal intubation, and the heart rate and mild pain are within expected postoperative ranges and do not pose an immediate life-threatening risk.
✦ 台美臨床差異
美國護理師在發現喘鳴時有獨立權限啟動緊急呼吸道護理程序；台灣通常會先呼叫值班醫師並準備急救車。