— 照護管理 · HARD · MCQ —
護理師在急診室工作，哪位病人應列為最高優先級？
A nurse is working in an emergency department. Which client should the nurse triage as the highest priority?
- AA client with a closed fracture of the ankle一位患有踝關節閉鎖性骨折的病人
- BA client with a superficial laceration on the forehead一位額頭有表淺撕裂傷的病人
- CA client with a history of fever for three days一位有三天發燒病史的病人
- DA client experiencing anaphylaxis after a bee sting✓ 正解一位被蜜蜂螫傷後發生過敏性休克的病人
— Explanation · 中文詳解 —
依據檢傷分類（Triage）原則，呼吸與循環功能受損者為最緊急個案。過敏性休克（Anaphylaxis）會導致嚴重的呼吸道水腫與血管擴張性休克，若不緊急介入（如 epinephrine），可能在數分鐘內死亡。其餘選項雖有不適，但皆非致命威脅。
According to triage principles, clients with compromised respiratory or circulatory function require the highest priority. Anaphylaxis causes airway edema and shock, which can be fatal within minutes without immediate intervention such as epinephrine administration. The other conditions described are stable and do not pose an immediate life-threatening risk.
✦ 台美臨床差異
美台檢傷系統（如 Triage System）皆一致，以 ABC 原則為核心。