— 照護管理 · EASY · MCQ —
護理師在內外科病房進行護理優先級評估，哪位病人應優先評估？
A nurse is prioritizing care on a medical-surgical unit. Which client should the nurse assess first?
- AA client with a scheduled dressing change for a surgical incision預約進行手術切口敷料更換的病人
- BA client waiting to be discharged with physician's orders等待醫師出院指示的病人
- CA client newly admitted with a potassium level of 6.2 mEq/L✓ 正解新入院且血鉀濃度為 6.2 mEq/L 的病人
- DA client requesting pain medication for a migraine要求止痛藥以緩解偏頭痛的病人
— Explanation · 中文詳解 —
高血鉀症（6.2 mEq/L）可能導致致命性心律不整（如心室顫動），屬於生命徵象不穩定，必須優先處理。其餘選項皆為常規護理活動，病情相對穩定。護理優先級需依據 ABC 原則，電解質失衡影響心臟功能屬於呼吸循環系統層面，具高度危險性。
The nurse should prioritize the client with a potassium level of 6.2 mEq/L because severe hyperkalemia poses an immediate risk of life-threatening cardiac dysrhythmias. According to ABC principles, electrolyte imbalances affecting cardiac function take precedence over routine tasks like dressing changes, discharge preparations, or pain management in hemodynamically stable clients.
✦ 台美臨床差異
台美均將電解質嚴重異常列為優先處理事項，但護理師在台灣需更依賴醫囑執行處置。