— 安全與感染控制 · HARD · MCQ —
護理師進入內外科病房時，應優先評估哪位病人？
Which client should the nurse see first upon entering the medical-surgical unit?
- AA client with a sudden onset of dyspnea and tachycardia✓ 正解突然出現呼吸困難與心搏過速的病人
- BA client requesting assistance to ambulate to the bathroom請求協助步行至洗手間的病人
- CA client reporting pain at the IV site with redness報告靜脈注射部位疼痛伴隨紅腫的病人
- DA client with a fever of 101.5°F (38.6°C) post-op day 2術後第二天發燒 101.5°F (38.6°C) 的病人
— Explanation · 中文詳解 —
在護理師進入病房評估多位病人時，必須運用 ABC（氣道、呼吸、循環）原則進行「分流（triage）」。突發性呼吸困難與心搏過速是肺栓塞或急性心衰竭的潛在徵兆，這些狀況具有致命風險且變化迅速，必須優先處理。發燒、靜脈注射部位紅腫或協助如廁的需求，雖需後續處理，但並不具備立即威脅生命（life-threatening）的急迫性。
When the nurse enters a unit to assess multiple clients, the ABC (Airway, Breathing, Circulation) principle must guide triage. Sudden onset dyspnea and tachycardia are potential signs of pulmonary embolism or acute heart failure; these conditions carry a high risk of death, can deteriorate rapidly, and must be addressed first. Fever, redness at an IV site, or a request for ambulation assistance require attention but do not represent immediately life-threatening urgency.