— 照護管理 · MEDIUM · MCQ —
護理師正在排列四位病人的照護優先順序，應優先看哪一位？
The nurse is prioritizing care for four clients. Which client should be seen first?
- AA client with pneumonia who has a pulse oximetry reading of 89% on room air.✓ 正解一位肺炎病患，在吸入空氣下脈搏血氧飽和度讀數為 89%。
- BA client with a blood glucose of 250 mg/dL and scheduled for insulin.一位血糖為 250 mg/dL 且預約注射胰島素的病患。
- CA client scheduled for surgery in 2 hours who is feeling anxious.一位兩小時後進行手術且感到焦慮的病患。
- DA client with a fractured hip who is reporting pain as 8 out of 10.一位髖骨骨折且報告疼痛指數為 10 分中的 8 分的病患。
— Explanation · 中文詳解 —
根據優先順序框架（Maslow, ABC, Unstable vs Stable），血氧 89%（A）代表急性缺氧，屬於呼吸系統不穩定，具最高優先權。血糖 250（B）雖高但非酮酸中毒的急性危險；疼痛（D）雖嚴重但非致命；焦慮（C）屬於心理層面，優先級最低。氧合問題（Airway/Breathing）始終先於疼痛或血糖波動。
The client with pneumonia and a pulse oximetry reading of 89% requires immediate attention because oxygen saturation below 90% indicates significant hypoxemia, posing an acute threat to physiological stability. While hyperglycemia, severe pain, and anxiety are important, they do not take precedence over compromised airway and breathing.
✦ 台美臨床差異
台美臨床對於 ABC 優先原則的應用一致，但在人力極度短缺時，護理師需具備強大的判斷力以應對多重緊急狀況。