— 降低風險 · MEDIUM · MCQ —
護理師照顧一名甲狀腺切除術後病人，下列哪項評估發現應優先視為呼吸道阻塞的徵象？
A nurse is caring for a client who is postoperative following a thyroidectomy. Which assessment finding should the nurse prioritize as an indicator of potential airway obstruction?
- APresence of audible stridor when the patient is breathing✓ 正解患者呼吸時出現可聽見的喘鳴聲
- BPatient complaining of mild pain at the incision site患者主訴切口處輕微疼痛
- CPatient reporting a sore throat when swallowing患者報告吞咽時喉嚨痛
- DDrainage of 20 mL of serosanguineous fluid in the drain引流管內有 20 mL 的血清血性液體流出
— Explanation · 中文詳解 —
甲狀腺切除術後需密切關注喉頭水腫或血腫壓迫氣管風險。喘鳴聲（stridor）是氣管狹窄或阻塞的關鍵聽診徵象，這代表呼吸道已受嚴重威脅，需立即通知醫師準備插管。術後疼痛與喉嚨痛屬常見併發症，引流量在一定範圍內為正常現象，皆非立即致命危機。
Audible stridor is a priority finding indicating laryngeal edema or hematoma compressing the airway after thyroidectomy, requiring immediate notification of the provider to prevent respiratory arrest.
✦ 台美臨床差異
美台臨床皆視喘鳴為急症；美國護理師常需更主動介入氣道評估並啟動快速反應小組（RRT）。