— 生理適應 · HARD · MCQ —
護理師監測甲狀腺切除術後病人，發現其出現喉鳴音與躁動，應優先採取什麼行動？
A nurse is monitoring a client post-thyroidectomy. The client exhibits laryngeal stridor and restlessness. Which action is the priority?
- AAdminister IV calcium gluconate靜脈注射葡萄糖酸鈣
- BNotify the surgeon immediately立即通知外科醫師
- CPrepare for emergency tracheostomy✓ 正解準備緊急氣管切開術
- DAssess the surgical site for hematoma評估手術部位是否有血腫
— Explanation · 中文詳解 —
喉鳴音（stridor）是呼吸道阻塞的徵象，甲狀腺手術後可能因喉返神經損傷、血腫壓迫或氣管塌陷造成致命性窒息。面對呼吸道危急狀況，準備急救氣管切開術（ tracheostomy）或插管以維持呼吸道通暢是最高優先級，切勿因等待檢查或藥物延誤治療。
Laryngeal stridor indicates life-threatening airway obstruction, which can result from laryngeal nerve damage, hematoma compression, or tracheal collapse post-thyroidectomy. The nurse's highest priority is preparing for emergency tracheostomy or intubation to secure the airway rather than delaying for assessment or medication.
✦ 台美臨床差異
在美國，護理師可根據醫院的緊急應變程序啟動呼吸道團隊，台灣則多需由值班醫師到場確認後方可執行。