下列哪些行為顯示護理師在緊急情況下能有效優先排序？（選所有適合的）
Which of the following indicates that a nurse effectively prioritizes care during an emergency? (Select all that apply.)
- AAttending to a client having an active seizure first優先處理正在發作的病人正確答案
- BPrioritizing the client who complains of severe chest pain優先處理主訴嚴重胸痛的病人正確答案
- CAssessing a client who is complaining of nausea after eating評估用餐後主訴噁心的病人
- DEnsuring airway patency before checking skin integrity在檢查皮膚完整性前先確保呼吸道暢通正確答案
- EPrioritizing an alert client over an unconscious one優先處理清醒的病人而非無意識者
- A優先處理正在發作的病人
- B優先處理主訴嚴重胸痛的病人
- D在檢查皮膚完整性前先確保呼吸道暢通
在緊急情況下，護理師必須快速且有效地判斷病人的危急程度，並依據「生命優先」的原則進行排序（prioritization）。這通常遵循 ABCDE 原則（Airway, Breathing, Circulation, Disability, Exposure）。 正確選項 A、B、D 都代表了需要立即處理的危急狀況。A. 癲癇發作中（active seizure）可能導致氣道阻塞或呼吸停止，屬於緊急事件。B. 突發性胸痛（sudden onset of chest pain）高度提示急性心肌梗塞或肺栓塞等危及生命的情況。D. 確保呼吸道暢通（airway patency）是所有評估與治療的首要步驟，優先於皮膚完整性等非立即危及生命的問題。 錯誤選項 C（噁心）雖然令人不適，但相較於癲癇、胸痛或氣道問題，其立即的生命威脅性較低。錯誤選項 E（優先處理意識清醒者）是錯誤的，通常意識喪失或改變代表更嚴重的病理生理變化，可能需要更優先的處理。 臨床推理：在緊急情況下，護理師需要拋開常規的評估順序，轉而關注那些可能在幾分鐘內導致死亡或嚴重後果的狀況。ABC 原則（Airway, Breathing, Circulation）是判斷優先順序的核心。安全優先：優先處理危及生命的狀況，能最大程度地挽救生命。
- A · 正確答案優先處理正在發作的病人
此選項正確。活躍的癲癇發作可能導致氣道阻塞、缺氧甚至呼吸停止，需要立即介入以保護氣道和生命安全。
- B · 正確答案優先處理主訴嚴重胸痛的病人
此選項正確。突發性嚴重胸痛是心臟驟停（cardiac arrest）或急性心肌梗塞的警訊，需要立即評估與處理，可能危及生命。
- C評估用餐後主訴噁心的病人
此選項錯誤。餐後噁心雖然令人不適，但通常不具立即的生命危險，優先順序低於有明顯生命威脅的狀況。
- D · 正確答案在檢查皮膚完整性前先確保呼吸道暢通
此選項正確。確保呼吸道暢通是 ABC 原則中的首要考量，任何情況下都應優先於其他非立即危及生命的評估，如皮膚完整性。
- E優先處理清醒的病人而非無意識者
此選項錯誤。意識狀態是判斷病人危急程度的重要指標。無意識的病人通常病情更嚴重，可能需要比意識清醒者更優先的處理。
緊急情況下的病人優先排序（triage）原則在台美兩地是高度一致的，均遵循國際公認的 ABCDE（Airway, Breathing, Circulation, Disability, Exposure）原則。兩地醫療體系都強調對危及生命狀況的優先處理。差異可能在於某些醫院的急診分級系統或資源分配上的細微差別，但核心的臨床決策邏輯相同。
English explanation
In emergency situations, the nurse must quickly and effectively determine the level of acuity and prioritize care based on the principle of "life first." This typically follows the ABCDE approach (Airway, Breathing, Circulation, Disability, Exposure). The correct options A, B, and D all represent critical conditions that require immediate management. A. An active seizure may lead to airway obstruction or respiratory arrest and is an emergency. B. Sudden onset of chest pain strongly suggests a life-threatening condition such as acute myocardial infarction or pulmonary embolism. D. Ensuring airway patency is the first step of all assessments and treatments, and takes precedence over non-immediately life-threatening issues such as skin integrity. Incorrect option C (nausea): although uncomfortable, it poses less immediate threat to life compared with seizures, chest pain, or airway issues. Incorrect option E (prioritizing an alert client) is wrong, because loss of consciousness or altered mental status usually represents more serious pathophysiologic change and may require even higher priority management. Clinical reasoning: In emergencies, the nurse must move away from routine assessment sequences and focus on conditions that may cause death or severe consequences within minutes. The ABC principle (Airway, Breathing, Circulation) is the core of priority setting. Safety first: prioritizing life-threatening conditions maximizes the likelihood of saving lives.
最近修訂：2026-10-06