— 照護管理 · MEDIUM · MCQ —
護理師在內外科病房同時照顧四位病人，哪一位應優先評估？
A nurse is working on a medical-surgical unit and is assigned to care for four clients. Which client should the nurse assess first?
- AA client who is 2 days post-appendectomy and has a temperature of 100.2°F一位腹腔切除術後第 2 天且體溫為 100.2°F 的病人
- BA client with type 2 diabetes who has a blood glucose level of 180 mg/dL一位血糖水平為 180 mg/dL 的第二型糖尿病病人
- CA client with a new cast on the left arm who reports tingling in the fingers✓ 正解一位左臂有新打石膏並報告手指有刺痛感的病人
- DA client with a history of heart failure who is complaining of shortness of breath有心衰竭病史且抱怨呼吸困難的病人
— Explanation · 中文詳解 —
護理優先順序原則應考量 ABC (呼吸、循環) 與潛在的致命性併發症。手指麻木（Tingling）暗示可能有腔室症候群（Compartment Syndrome），屬於神經血管受壓的緊急狀況，若不處理可能導致不可逆的組織壞死。心衰竭病人呼吸困難固然重要，但在神經血管受損的緊急程度下，肢體缺血的優先級更高。
The nurse should prioritize the client with the new cast reporting tingling, as this indicates potential neurovascular compromise or compartment syndrome, which can lead to irreversible tissue damage if not addressed immediately. Although shortness of breath is urgent, preventing permanent limb ischemia takes precedence over managing stable postoperative fever or mild hyperglycemia.
✦ 台美臨床差異
台美臨床對腔室症候群的警覺度均高，護理師需熟練執行 5P 評估以進行即時處置。