— 照護管理 · EASY · MCQ —
護理師在急診進行檢傷分類，哪一位病人應優先照護？
A nurse is triaging clients in the emergency department. Which client should the nurse see first?
- AA client with a closed fracture of the forearm reporting 6/10 pain前臂閉合性骨折主訴 6/10 疼痛的病患
- BA client with a sprained ankle and mild edema踝關節扭傷伴輕微水腫的病患
- CA client with a superficial laceration on the forehead actively bleeding✓ 正解額頭淺層割傷且活動性出血的病患
- DA client with suspected appendicitis who has a fever and RLQ pain疑似闌尾炎且有發燒與右下腹痛的病患
— Explanation · 中文詳解 —
急診檢傷分類（Triage）的核心依據是 ABC 原則。活動性出血（active bleeding）代表循環系統受損，若不處理可能導致低血容積休克，是急診中最具時效性的威脅。骨折（closed fracture）、闌尾炎（無穿孔徵兆）及踝關節扭傷雖然需要醫療處置，但在生命徵象穩定的前提下，其優先級低於活動性出血。護理師必須在秒級之內判斷病人的危急程度。
The nurse should see the client with active bleeding first because it poses an immediate threat to hemodynamic stability and potential shock. According to triage principles, addressing active hemorrhage takes priority over stable fractures, sprains, or non-perforated appendicitis. Rapid intervention is necessary to maintain circulation.