一位病人剛接受完甲狀腺切除術後 2 小時。病人表示脖子有「緊繃感」，且頻繁清喉嚨。護理師的優先行動為何？
A nurse is caring for a client who is 2 hours post-thyroidectomy. The client reports a feeling of 'fullness' in the neck and is frequently clearing their throat. Which is the nurse's priority action?
- AAssess the back of the neck for bleeding and check the surgical site for swelling.✓ 正解檢查頸後是否有出血，並查看手術部位是否有腫脹。
- BEncourage the client to use an incentive spirometer.鼓勵病人使用誘發性肺量計。
- CPosition the client in a supine position to stabilize the neck.將病人置於仰臥位以穩定頸部。
- DAdminister an ordered opioid analgesic for neck pain.給予處方的鴉片類鎮痛劑以緩解頸部疼痛。
甲狀腺切除術後最致命的併發症是術後出血導致的氣道壓迫。病人自訴脖子有緊繃感、感覺領口變緊或頻繁清喉嚨，往往是血腫壓迫氣管或喉部受損的早期警訊。根據 ABC 優先原則，護理師必須立即評估氣道完整性與是否有出血跡象。由於重力作用，血液常會流向頸後，因此只看前方敷料是不夠的，必須檢查頸部後方。若發現頸部圍距增加或明顯腫脹，應立即通報並準備緊急氣切組。本題核心在於識別「氣道受威脅」的微妙徵象，而非單純的術後疼痛處理。比起給藥或深呼吸練習，確保呼吸道通暢是生存關鍵。仰臥位反而會加重腫脹並增加氣道壓力，故應維持半坐臥位。
The priority action is to assess the back of the neck and surgical site for bleeding, as post-thyroidectomy hemorrhage can rapidly compress the airway. Blood often tracks down to the posterior neck, so checking only the anterior incision may miss early signs of a developing hematoma that threatens respiratory patency.
在美國護理執業中，懷疑術後血腫時護理師有權立即啟動 Rapid Response Team (RRT) 並在床邊準備氣切包；台灣臨床上則通常先通報住院醫師或主治醫師到場評估，再依醫囑準備急救設備，反應層級啟動機制略有不同。