— 生理適應 · HARD · MCQ —
護理師照護一名甲狀腺切除術後兩小時的病人，發現病人出現喘鳴聲且躁動不安。護理師應優先採取何項措施？
A nurse is caring for a client who is two hours post-operative after a thyroidectomy. The nurse notes the client has stridor and increased restlessness. What is the priority nursing action?
- ACall the primary surgeon immediately立即通知主治外科醫師
- BPlace the client in a high-Fowler's position將個案置於高福勒氏臥位
- CPrepare for emergency bedside tracheostomy✓ 正解準備緊急床邊氣管造廔術
- DAdminister the prescribed pain medication給予處方的止痛藥物
— Explanation · 中文詳解 —
甲狀腺切除術後出現喘鳴（stridor）是氣道阻塞的警訊，通常由術後出血造成的血腫壓迫氣管或喉頭水腫引起。這是會致命的緊急狀況，必須立即備妥氣管切開術器械包，以防呼吸道完全阻塞，這是護理師維持 ABC（氣道、呼吸、循環）原則中的首要任務。
Stridor following a thyroidectomy is a critical sign of airway obstruction, often caused by laryngeal edema or a hematoma compressing the trachea. This represents an immediate threat to the airway (ABCs), necessitating the preparation for an emergency bedside tracheostomy to secure the airway before calling the surgeon.
✦ 台美臨床差異
美國護理訓練強調在床邊準備插管用物；台灣臨床常需等待麻醉科或外科醫師到場，但護理師仍應先行備妥急救車。