— 照護管理 · HARD · MCQ —
交班報告後，護理師應優先評估哪位病人？
A nurse receives a change-of-shift report. Which client should the nurse assess first?
- AA client complaining of sudden unilateral calf pain and swelling✓ 正解主訴單側小腿疼痛和腫脹的病人
- BA client with a hemoglobin level of 9.2 g/dL血紅素為9.2 g/dL的病人
- CA client scheduled for discharge later in the day當天晚些時候準備出院的病人
- DA client waiting for pain medication for mild discomfort等待輕微不適止痛藥物的病人
— Explanation · 中文詳解 —
在 NCLEX 的優先順序（Priority setting）中，應根據 ABC（氣道、呼吸、循環）及病人不穩定性來決定。單側小腿疼痛與腫脹是深部靜脈栓塞（DVT）的典型症狀，這代表血栓可能隨時脫落導致肺栓塞（PE），這是危及生命的緊急情況，因此該病人應優先評估。其他選項雖需關注，但皆不屬於即刻生命威脅。
The nurse should assess the client with sudden unilateral calf pain and swelling first, as these are classic signs of deep vein thrombosis (DVT). This condition poses an immediate risk of pulmonary embolism, a life-threatening complication, making it a higher priority than stable lab values, discharge planning, or mild pain.