— 照護管理 · EASY · MCQ —
護理師同時照護四位病人，應優先評估哪一位？
The nurse is assigned to four clients. Which client should the nurse assess first?
- AA client awaiting discharge papers to go home一位等待出院文件回家的病人
- BA client who is complaining of sudden shortness of breath✓ 正解一位抱怨突然呼吸困難的病人
- CA client with a scheduled physical therapy session in 30 minutes一位 30 分鐘後有物理治療預約的病人
- DA client with chronic back pain requesting a heating pad一位因慢性背痛請求使用熱敷墊的病人
— Explanation · 中文詳解 —
優先順序應遵循 ABC（呼吸、循環、意識）原則。突然出現的呼吸困難（B）代表可能發生肺栓塞、氣胸或急性心衰竭，具有潛在生命危險，必須立即處理。疼痛（D）、復健安排（C）與出院流程（A）均非緊急或危及生命的狀況。
Prioritization should follow the ABC (airway, breathing, circulation/consciousness) framework. Sudden onset of shortness of breath (B) suggests possible pulmonary embolism, pneumothorax, or acute heart failure, which are potentially life-threatening and must be addressed immediately. Pain (D), scheduled rehabilitation (C), and discharge processing (A) are neither emergent nor life-threatening.
✦ 台美臨床差異
台美在優先順序判斷原則（ABC）上完全一致，但在人力不足時，行政流程常會干擾護理師的評估優先級。