護理師照護一位甲狀腺切除術後病人，哪項評估結果需要立即處置？
A nurse is caring for a client following a thyroidectomy. Which assessment finding requires immediate intervention by the nurse?
- APain at the incision site切口處疼痛
- BDrainage on the neck dressing頸部敷料有滲液
- CHoarseness when speaking說話時聲音沙啞
- DNoisy, high-pitched respirations✓ 正解呼吸聲雜亂且音調高
甲狀腺切除術後最嚴重的危險是呼吸道阻塞（可能由喉頭水腫、出血壓迫或甲狀腺風暴引起）。高頻率的雜音（stridor）代表氣管受到壓迫或腫脹，屬於呼吸窘迫前兆，必須立即通知醫師準備緊急插管或切開氣管。聲音沙啞（C）為常見喉返神經受刺激，雖需關注但非立即威脅生命。
The most serious risk after thyroidectomy is airway obstruction (which may be caused by laryngeal edema, bleeding with compression, or thyroid storm). Noisy, high-pitched respirations (stridor) indicate compression or swelling of the trachea and are a warning sign of impending respiratory distress; the physician must be notified immediately to prepare for emergency intubation or tracheostomy. Hoarseness (option C) is a common manifestation of recurrent laryngeal nerve irritation; although it warrants attention, it is not an immediately life-threatening finding.
美國護理師對於術後評估（Airway assessment）的權限極大，能直接啟動緊急醫療小組（RRT）；台灣護理師通常先向醫師回報。