護理師在內外科病房照顧一組病人，應優先看哪一位？
A nurse is caring for a group of clients on a medical-surgical unit. Which client should the nurse see first?
- AA client with a history of heart failure who has 2+ pitting edema in the lower extremities.有心衰竭病史，下肢有 2+ 凹陷性水腫的病人。
- BA client who is 1 day post-appendectomy and has not yet voided this shift.闌尾切除術後第 1 天，當班尚未排尿的病人。
- CA client with a stroke who has slurred speech and right-sided weakness.有中風病史，出現語謇和右側無力症狀的病人。
- DA client with a DVT who reports sudden pleuritic chest pain and shortness of breath.✓ 正解有深靜脈血栓（DVT）病史，主訴突發胸膜性胸痛和呼吸困難的病人。
深層靜脈栓塞（DVT）病人若出現突然的肋膜性胸痛與呼吸困難（D），高度懷疑為肺栓塞（PE），這是危及生命的緊急情況（Circulation/Breathing）。心衰竭水腫（A）是預期中的慢性表現；術後未解尿（B）需處理但非立即致命；中風症狀（C）若為既有症狀則屬穩定，PE 是最緊急的併發症。
In a patient with deep vein thrombosis (DVT), the sudden onset of pleuritic chest pain and dyspnea (D) raises high suspicion for pulmonary embolism (PE), a life-threatening emergency (Circulation/Breathing). Heart failure-related edema (A) is an expected chronic finding; postoperative urinary retention (B) requires intervention but is not immediately life-threatening; stroke symptoms (C), if pre-existing, are considered stable. PE is the most urgent complication.
此題考驗對致命併發症（PE）的警覺。在美國，PE 處置流程極快；台灣則需迅速回報並進行 CT 掃描診斷。