一名剛畢業的註冊護理師 (RN) 向護理長尋求協助，以安排四位指派病患的照護優先順序。剛畢業的 RN 必須首先全面評估哪一位病患？
A newly graduated registered nurse (RN) asks the charge nurse for assistance in prioritizing care for four assigned clients. Which client must the newly graduated RN comprehensively assess first?
- AA 50-year-old male admitted with deep vein thrombosis currently reporting a 4/10 aching pain in his right calf while receiving continuous IV heparin.一名50歲男性因深部靜脈血栓形成入院，目前在接受連續靜脈注射肝素治療，主訴右小腿有4/10的痠痛。
- BA 70-year-old female admitted for pneumonia who just triggered a high-pressure alarm on her continuous BiPAP machine.✓ 正解一名70歲女性因肺炎入院，其持續性雙水平陽壓通氣（BiPAP）機器剛剛觸發高壓警報。
- CA 65-year-old male with chronic COPD scheduled for discharge today eagerly pressing the call light to ask about his home oxygen tank delivery.一名65歲男性患有慢性阻塞性肺病（COPD），預計今天出院，正急切地按呼叫鈴詢問居家氧氣鋼瓶的送達事宜。
- DA 40-year-old male who is 4 hours post-laparoscopic appendectomy and has not yet successfully voided urine.一名40歲男性，腹腔鏡式闌尾切除術後4小時，尚未成功排尿。
本題測驗護理優先順序之 ABC 原則 (Prioritization: Airway, Breathing, Circulation)。運用「ABC」加上「急性與危及生命 (Acute/Life-threatening)」的法則來過濾選項。選項 B 的 70 歲肺炎病患正在使用雙層正壓呼吸器 (BiPAP)，且機器觸發了『高壓警報 (High-pressure alarm)』。BiPAP 的高壓警報意味著發生了機械或生理阻塞，例如病患因為濃痰堵塞呼吸道、發生支氣管痙攣或氣胸，導致機器打不進去空氣。這是直接影響「Airway 與 Breathing」的絕對紅色急症，一旦機器無法通氣，病患將迅速缺氧猝死。必須立即進入病房評估並抽痰。選項 A 的深部靜脈血栓 (DVT) 且有小腿痛，這是 DVT 的典型與預期表現，且已經有 Heaprin 在介入，病情相對穩定。選項 D 術後 4 小時未解尿是一項關注點，但術後一般有 6-8 小時的解尿寬限期，這不會立即致命。選項 C 出院問題屬於非緊急的行政衛教。
The nurse must prioritize the client with pneumonia triggering a high-pressure BiPAP alarm, as this indicates a potential airway obstruction or respiratory distress requiring immediate intervention. This represents an acute threat to the airway and breathing, whereas the other clients present with stable or non-urgent conditions.
高壓呼吸警報 (High-pressure alarm) 的處理：無庸置疑的第一優先。只要機器叫了，必定是 Airway 被塞住 (痰液、氣管咬管、氣胸)，不管台美都是立刻衝進去救的紅色警戒。