— 生理適應 · HARD · MCQ —
病人因臉部與頸部燒傷入院。護理師最優先關切的問題為何?
A client is admitted with burns on the face and neck. What is the nurse's primary concern?
- AFluid volume deficit體液不足
- BInfection prevention感染預防
- CPain management疼痛管理
- DAirway patency✓ 正解呼吸道通暢
— Explanation · 中文詳解 —
在燒傷病人的急救護理中,ABC(Airway, Breathing, Circulation)原則為最高指導原則。臉部與頸部燒傷極易合併吸入性傷害,氣道黏膜會迅速發生水腫,導致呼吸道阻塞。即使病人入院時呼吸看起來尚可,水腫進展速度極快,若不及時建立人工氣道,可能在短時間內導致窒息。因此,維持呼吸道通暢是護理師最優先的責任。
The nurse's primary concern for a client with burns on the face and neck is maintaining airway patency due to the risk of rapid edema and inhalation injury. According to the ABCs of emergency care, securing the airway takes precedence over fluid resuscitation, infection prevention, or pain management, as airway obstruction can be immediately life-threatening.