— 降低風險 · HARD · MCQ —
護理師照護一位甲狀腺切除術後返室的病人。下列哪一項評估發現是護理師需優先回報醫師的？
A nurse is caring for a client who has just returned from a thyroidectomy. Which assessment finding is the priority for the nurse to report to the surgeon?
- AIncisional pain rated 4/10切口疼痛評分為 4/10
- BNoisy, high-pitched respirations✓ 正解嘈雜、高音調的呼吸聲
- CMild hoarseness when speaking說話時輕微聲音沙啞
- DNeck dressing is dry and intact頸部敷料乾燥且完整
— Explanation · 中文詳解 —
甲狀腺術後最危急的併發症為呼吸道阻塞。喘鳴聲（stridor）通常代表喉頭水腫或聲帶麻痺導致的呼吸道狹窄，若不立即處理將迅速演變為呼吸窘迫。其餘選項中，聲音沙啞可能是喉返神經損傷但非立即致命，傷口疼痛和乾燥敷料均在預期範圍內。
After a thyroidectomy, the nurse must prioritize assessing for airway compromise, as stridor indicates potential laryngeal edema or hematoma causing obstruction. This is a life-threatening emergency that requires immediate reporting, whereas mild hoarseness, manageable pain, and intact dressings are expected findings or less urgent concerns.
✦ 台美臨床差異
美台臨床皆視喘鳴為急症，但在美國護理師常依據預先核准之緊急流程（protocol）準備氣切工具，台灣則多依醫師臨床判斷為主。