— 安全與感染控制 · HARD · MCQ —
接班後，護理師應優先評估下列哪位病人？
Which client should the nurse see first upon receiving the shift report?
- AA client scheduled for discharge with a stable wound dressing傷口敷料穩定且準備出院的病人
- BA client with a new onset of sudden confusion and restlessness✓ 正解新出現突然意識混亂和煩躁不安的病人
- CA client with a fever of 101.2°F complaining of a mild headache體溫101.2°F並抱怨輕微頭痛的病人
- DA client receiving IV antibiotics who has a loose IV dressing接受靜脈抗生素治療且敷料鬆脫的病人
— Explanation · 中文詳解 —
根據 ABC（呼吸、循環、氣道）原則與安全優先級，新出現的意識改變（confusion/restlessness）可能暗示腦部缺氧、敗血症或急性代謝失調，屬於急症，需立即處置。其他選項雖需處理，但相對穩定。
The nurse should prioritize the client with sudden confusion, as this may indicate acute hypoxia, stroke, or sepsis requiring immediate assessment. Other clients have stable conditions or routine needs that do not pose an immediate threat to life or safety.
✦ 台美臨床差異
台美護理教育皆高度強調臨床判斷與優先級排序，此類考題為 NCLEX 與台灣護理師考試重點。