護理師剛完成交班,收到四位病人的資訊。護理師應優先評估哪位病人?
A nurse has just received the change-of-shift report for four clients. Which client should the nurse assess first?
- AA client with pneumonia who has a pulse oximetry reading of 91% on 2 L/min oxygen肺炎病人,在吸入 2 L/min 氧氣下脈搏血氧飽和度讀數為 91%
- BA client with a deep vein thrombosis (DVT) who reports sudden shortness of breath✓ 正解深層靜脈血栓形成 (DVT) 病人,主訴突然呼吸困難
- CA client who underwent an abdominal surgery 4 hours ago and reports pain as 8/10四小時前接受腹部手術的病人,主訴疼痛指數為 8/10
- DA client with chronic renal failure awaiting scheduled hemodialysis in 2 hours慢性腎衰竭病人,等待兩小時後進行常規血液透析
在臨床優先順序(Prioritization)中,護理師應遵循 ABC(呼吸道、呼吸、循環)以及「急性優於慢性」、「不穩定優於穩定」的原則。選項 B 的病人患有深層靜脈栓塞(DVT),突然出現呼吸困難,這高度懷疑是肺栓塞(PE),這是一個潛在致命且極不穩定的急性狀況,直接威脅生命,必須立即評估。選項 A 的肺炎病人 SpO2 91% 雖稍低但尚在可接受範圍(尤其是呼吸道感染時);選項 C 術後疼痛雖需處理,但疼痛通常非立即致命;選項 D 是慢性狀況,且洗腎是預定計畫。根據優先權排序,B 選項是典型的『危急突發狀況』,必須排在首位。
A client with deep vein thrombosis (DVT) who reports sudden shortness of breath is likely experiencing a pulmonary embolism, a life-threatening emergency. According to ABC principles, this unstable, acute respiratory compromise takes priority over stable chronic conditions or expected postoperative pain.
美國 NCLEX 考題極度強調「穩定度」與「潛在風險」,護理師被訓練成獨立判斷病情的決策者;台灣臨床環境中,雖然也會依急迫性處理,但有時會受限於醫師巡房時間或科別界限,導致護理師在跨科別優先順序上的自主權與美國相比略有不同。