護理師照護一位甲狀腺切除術後 2 小時的病人，哪項發現需護理師立即介入？
A nurse is caring for a client who is 2 hours post-operative after a thyroidectomy. Which finding requires the nurse's immediate intervention?
- ASerosanguinous drainage on the dressing敷料上有血清血性滲出物
- BPatient complains of a sore throat when swallowing病患主訴吞嚥時喉嚨痛
- CRespiratory stridor upon inspiration✓ 正解吸氣時出現呼吸喘鳴
- DHeart rate of 92 beats per minute心率为每分钟 92 次
甲狀腺切除術後，最嚴重的併發症是氣道阻塞。喉部喘鳴（Inspiratory stridor）代表氣道因水腫或血腫而狹窄，這是隨時可能導致窒息的急徵。護理師一旦觀察到喘鳴音，必須立即通知外科醫師，並準備好氣切包與急救設備，以便隨時進行人工氣道建立。其他如傷口滲出、輕微心跳過速雖然也需監測，但氣道安全絕對是術後評估的最高優先級。
The most serious complication after thyroidectomy is airway obstruction. Inspiratory stridor indicates airway narrowing due to edema or hematoma and is an acute warning sign that may lead to suffocation at any time. Once stridor is detected, the nurse must immediately notify the surgeon and have a tracheostomy kit and emergency equipment ready, so that an artificial airway can be established at any time. Other findings such as wound drainage or mild tachycardia also require monitoring, but airway safety is absolutely the top priority of postoperative assessment.