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✓ 正解優先處理正在發作的病人
- BPrioritizing the client who complains of severe chest pain✓ 正解優先處理主訴嚴重胸痛的病人
- 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✓ 正解在檢查皮膚完整性前先確保氣道暢通
- EPrioritizing an alert client over an unconscious one優先處理清醒的病人而非無意識者
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. 主動癲癇發作（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. 確保氣道暢通（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。 臨床思路：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）是判斷優先級的核心。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。
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.
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。