— 照護管理 · MEDIUM · MCQ —
護理師負責四位病人，哪一位應優先處理？
A nurse is managing the care of four clients. Which client should the nurse see first?
- AA client with a chest tube showing 50 mL of drainage in the last 2 hours一位胸管引流最近 2 小時內有 50 mL 的病人
- BA client with COPD who has a new onset of sudden confusion✓ 正解一位慢性阻塞性肺病（COPD）且新發突發性意識混亂的病人
- CA client with a total hip replacement reporting pain of 6/10一位全髖關節置換術後報告疼痛程度為 6/10 的病人
- DA client with type 2 diabetes who has a blood glucose of 180 mg/dL一位血糖為 180 mg/dL 的第二型糖尿病病人
— Explanation · 中文詳解 —
依據 ABCs（呼吸、循環、氣道）原則，護理評估應優先處理急性生理改變。COPD 病人出現意識混亂常為嚴重缺氧或二氧化碳滯留（高碳酸血症）的警訊，具生命威脅性。其他選項如疼痛、引流量或血糖偏高，雖需處理但皆非立即危及生命。
According to the ABCs (Airway, Breathing, Circulation) priority principle, nursing assessment should first address acute physiological changes. The new onset of confusion in a COPD patient is often a warning sign of severe hypoxia or carbon dioxide retention (hypercapnia) and is life-threatening. Other options such as pain, drainage volume, or elevated blood glucose require management but are not immediately life-threatening.
✦ 台美臨床差異
triage 臨床邏輯兩地一致。但在台灣臨床，護理師需在醫師指示下給予緊急氧氣，美國護理師依據護理 protocol 的自主執行權限通常較大。