護理師正在為內外科病房的一組病人進行護理優先順序排序。哪一位病人應優先進行評估？
A nurse is prioritizing care for a group of clients on a medical-surgical unit. Which client should the nurse assess first?
- AA client receiving IV antibiotics who needs an assessment of the infusion site.正在接受靜脈抗生素治療且需要評估輸液部位的病人
- BA client with COPD who is complaining of increased shortness of breath and agitation.✓ 正解患有慢性阻塞性肺疾病（COPD）並主訴呼吸困難加重及煩躁不安的病人
- CA client with diabetes scheduled for a dressing change on a non-healing foot ulcer.預約進行未癒合足部潰瘍換藥的糖尿病病人
- DA client who is 2 hours post-op from a cholecystectomy and reports pain level 6 out of 10.膽囊切除術後 2 小時並報告疼痛程度為 6/10 的病人
護理優先順序的核心是根據 ABC 原則（氣道、呼吸、循環）。COPD 病人出現呼吸困難加劇合併躁動（Agitation），這是缺氧導致腦部灌流不足的警訊，隨時可能演變成呼吸衰竭，必須立即處理以確保氣道與呼吸功能。C 選項屬慢性傷口護理，優先級最低；D 選項雖然有疼痛，但屬於術後預期症狀，生命徵象穩定即可處理；A 選項僅為常規護理評估，穩定但非緊急。臨床思路應區分穩定病人與不穩定病人，呼吸窘迫者永遠是第一優先的救命對象。
Respiratory distress accompanied by agitation indicates potential hypoxia and impending respiratory failure, making it the highest priority under the ABC framework. While IV site checks, dressing changes, and pain management are important, they do not pose an immediate threat to life compared to compromised airway and breathing.
美國護理師在面對此類 triage 時常運用 ADPIE 邏輯，對於呼吸衰竭前兆的病患，護理師有權立即啟動 Rapid Response Team (RRT)；在台灣，此類情況護理師多先評估後通知值班醫師，對於啟動緊急醫療團隊的權限與機制較為保守。