— 照護管理 · HARD · MCQ —
晨間交班後，護理師應優先評估哪位病人？
Which of the following patients should the nurse assess first after receiving the morning report?
- AA patient with pneumonia who has a persistent dry cough患有肺炎且有持續乾咳的病人
- BA patient post-femoral catheterization who has a new pedal pulse deficit✓ 正解股動脈導管置入術後出現新發足背脈搏減弱的病人
- CA patient with stable angina who has had no chest pain for 24 hours患有穩定型心絞痛且24小時內無胸痛症狀的病人
- DA patient with chronic heart failure who has 1+ pedal edema患有慢性心衰竭且有1+足部水腫的病人
— Explanation · 中文詳解 —
動脈穿刺術後，足背動脈搏動缺失是血管阻塞或血腫壓迫的急性警訊，極可能造成肢體缺血壞死，屬於血管緊急情況。其他選項中，穩定型心絞痛、肺炎咳嗽、慢性心衰竭水腫均屬於病程發展中的預期狀況，優先級低於急性血管循環問題。
After arterial catheterization, an absent dorsalis pedis pulse is an acute warning sign of vascular occlusion or hematoma compression and is highly suggestive of impending limb ischemia and necrosis, representing a vascular emergency. The other options, stable angina, cough due to pneumonia, and edema from chronic heart failure, all represent expected findings within the course of the underlying disease and are of lower priority than an acute vascular circulatory problem.
✦ 台美臨床差異
此題體現 ABC (Airway, Breathing, Circulation) 原則，循環受損在兩地臨床評估中皆列為最高優先級。