— 照護管理 · HARD · MCQ —
護理師在急診檢傷區工作，哪位病人應優先處理？
A nurse is working in the triage area of an emergency department. Which client should the nurse see first?
- AA client with an asthma attack and audible wheezing at rest✓ 正解發生氣喘發作且在靜止時可聽到喘鳴聲的病人
- BA client with a mild headache for two days頭痛兩天且症狀輕微的病人
- CA client with a closed forearm fracture complaining of severe pain前臂閉鎖性骨折並主訴劇烈疼痛的病人
- DA client with a superficial laceration requiring sutures需要縫合淺層撕裂傷的病人
— Explanation · 中文詳解 —
急診檢傷原則依呼吸、循環及危險程度判斷。氣喘發作且靜止時即有喘鳴聲，代表呼吸道阻塞嚴重，面臨呼吸衰竭風險，屬於一級或二級緊急個案。其餘選項（骨折、撕裂傷、頭痛）雖需治療，但呼吸系統的急迫性遠高於骨科或輕症。
Emergency department triage is based on breathing, circulation, and severity of risk. An asthma exacerbation with audible wheezing at rest indicates significant airway obstruction and risk of respiratory failure, classifying the client as Level 1 or 2 urgency. The other options (fracture, laceration, headache) require treatment, but respiratory urgency far outweighs orthopedic or minor complaints.
✦ 台美臨床差異
台美皆採檢傷分級制度，但美國急診護理師（ENPC/TNCC）在分級後續處置的主導權較大。