— 降低風險 · HARD · MCQ —
護理師評估甲狀腺切除術後 4 小時的病人，發現喉鳴與呼吸窘迫。哪項行動為優先？
A nurse is assessing a client 4 hours after a thyroidectomy. The nurse notes laryngeal stridor and respiratory distress. Which action is the priority?
- AAdminister oxygen via non-rebreather mask通過非再呼吸面罩給氧
- BPrepare for emergency tracheostomy✓ 正解準備緊急氣管切開術
- CElevate the head of the bed to 90 degrees將床頭抬高至 90 度
- DAdminister IV calcium gluconate靜脈注射葡萄糖酸鈣
— Explanation · 中文詳解 —
甲狀腺術後喉鳴是喉頭水腫或血腫壓迫氣道的警訊，隨時可能發生完全氣道阻塞。準備緊急氣切或插管設備是維持呼吸道通暢的優先措施。供氧無法解決機械性阻塞，鈣劑治療手足抽搐，墊高床頭僅為輔助，皆無法立即解決窒息風險。
Laryngeal stridor and respiratory distress after thyroidectomy suggest airway compromise from edema or hematoma, which is a medical emergency. Immediate preparation for emergency intubation or tracheostomy is required to maintain airway patency, as oxygen alone cannot relieve mechanical obstruction.
✦ 台美臨床差異
台美均將維持氣道列為最高優先，美國護理師常攜帶氣切包於床邊，台灣則依據醫院評鑑規範，高危單位需配置氣切設備。