NurslixJournal
降低風險 · HARD · MCQ

護理師照護一位甲狀腺切除術後 2 小時的病人,發現病人吸氣時出現高音調呼吸音。哪項措施最優先?

A nurse is caring for a client who is 2 hours post-operative after a thyroidectomy. The nurse notes the client has developed a high-pitched respiratory sound during inhalation. Which action is the priority?

  • AAdminister an analgesic for pain
    給予止痛劑以緩解疼痛
  • BPrepare the bedside suction
    準備床邊抽吸裝置
  • CPlace the client in a high-Fowler's position
    將個案置於高福勒氏臥位
  • DNotify the surgeon immediately✓ 正解
    立即通知外科醫師
Explanation · 中文詳解

甲狀腺切除術後若出現喘鳴音(Stridor),代表喉頭水腫或聲帶麻痺導致氣道阻塞,這是危及生命的緊急情況,必須立即通知外科醫師並備妥氣管內插管或切開術準備。優先處理 ABC 中的 Airway 穩定,通知醫師為啟動後續急救程序之關鍵。

Stridor after thyroidectomy indicates laryngeal edema or vocal-cord paralysis causing airway obstruction. This is a life-threatening emergency and the surgeon must be notified immediately, with endotracheal intubation or tracheostomy equipment readied. Within the ABCs, stabilization of the Airway takes precedence, and notifying the provider is the key step that initiates the subsequent emergency response.

✦ 台美臨床差異

美國護理師常攜帶氣切包在旁(Stridor tray);台灣病房通常依賴呼叫醫師團隊或麻醉科處理。

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