— 照護管理 · MEDIUM · MCQ —
護理師照護一位新接受氣切的病人，病人焦慮且呼吸困難。護理師應優先執行哪項措施？
A nurse is caring for a client with a new tracheostomy. The client is anxious and has difficulty breathing. Which nursing action should be performed first?
- AAssess the client's respiratory status✓ 正解評估病人的呼吸狀況
- BAdminister oxygen via nasal cannula經鼻導管給予氧氣
- CNotify the physician通知醫師
- DSuction the tracheostomy tube抽吸氣切套管
— Explanation · 中文詳解 —
面對呼吸窘迫的病人，護理師應遵循護理過程（Nursing Process）的優先順序，首要步驟為「評估（Assessment）」。氣切病人出現呼吸困難可能有多種原因，包括痰液阻塞、氣管套管移位、氣胸或氣管痙攣等。在採取任何介入措施（如抽痰或給氧）之前，必須先收集客觀數據，以判斷問題的來源。若未經評估直接抽痰，可能導致病人更加焦慮或錯過其他致命性併發症的診斷時機。
The nurse must first assess the client's respiratory status to identify the cause of distress, such as mucus plugging or tube displacement. Assessment guides subsequent interventions like suctioning or oxygen administration, ensuring safe and appropriate care before notifying the provider.