— 生理適應 · MEDIUM · MCQ —
護理師應優先評估哪位病人？
Which client should the nurse prioritize for assessment?
- AClient with a heart rate of 95 bpm心率為 95 bpm 的病人
- BClient with an oxygen saturation of 94%血氧飽和度為 94% 的病人
- CClient with a blood pressure of 110/70 mmHg血壓為 110/70 mmHg 的病人
- DClient with a respiratory rate of 28 breaths/min✓ 正解呼吸頻率為 28 breaths/min 的病人
— Explanation · 中文詳解 —
在 NCLEX 考試中，處理病人優先順序（Prioritization）的核心邏輯是遵循 ABC（氣道 Airway、呼吸 Breathing、循環 Circulation）原則。呼吸頻率 28 次/分屬於頻速呼吸（Tachypnea），明顯超出正常範圍（12-20 次/分），這通常是呼吸窘迫、代謝性酸中毒或疼痛等生理代償的跡象，具有潛在的惡化風險。相較於其他選項，此數據直接反映了氣體交換能力的受損，必須優先處理。
The nurse must prioritize the client with a respiratory rate of 28 breaths/min because tachypnea indicates potential respiratory distress or compromised gas exchange. According to the ABC (Airway, Breathing, Circulation) framework, breathing abnormalities take precedence over stable vital signs such as normal heart rate, oxygen saturation, or blood pressure.