— 照護管理 · MEDIUM · MCQ —
護理師在長照機構工作。哪位病人應優先處理？
A nurse is working in a long-term care facility. Which client should the nurse see first?
- AA client with a pressure ulcer requiring a dressing change患有需更換敷料的壓瘡的病人
- BA client scheduled for their daily insulin dose預約每日胰島素劑量的病人
- CA client reporting sudden onset of chest pain✓ 正解主訴突發胸痛的病人
- DA client waiting for family to bring lunch等待家屬送午餐的病人
— Explanation · 中文詳解 —
在護理優先級評估中，必須遵循「ABC原則」（呼吸道 Airway、呼吸 Breathing、循環 Circulation）以及生命體徵不穩定性。胸痛是急性心肌梗塞（MI）的典型症狀，屬於循環系統急症，若未及時處置可能導致心律不整或心跳停止，因此必須作為第一順位處理。其餘選項如敷料更換、常規給藥或等待家屬，均屬於穩定的長期照護範疇，不具備立即威脅生命的風險。
In nursing prioritization, follow the ABC principle (Airway, Breathing, Circulation) and vital sign instability. Chest pain is a typical symptom of acute myocardial infarction (MI), a circulatory emergency that can lead to arrhythmia or cardiac arrest if untreated, so it must be addressed first. Other options like dressing change, routine medication, or waiting for family fall under stable long-term care without immediate life-threatening risk.