— 降低風險 · HARD · MCQ —
甲狀腺切除術後 4 小時，病人出現喉鳴（stridor）。護理師應採取的最優先措施為何？
A nurse is assessing a client 4 hours post-thyroidectomy. The client exhibits laryngeal stridor. Which action is the nurse's priority?
- APrepare for emergency tracheostomy✓ 正解準備進行緊急氣管切開術
- BAdminister IV calcium gluconate靜脈注射葡萄糖酸鈣
- CElevate the head of the bed to 45 degrees將床頭抬高至 45 度
- DAssess for Chvostek's sign評估 Chvostek 徵象
— Explanation · 中文詳解 —
甲狀腺切除術（Thyroidectomy）後，喉鳴（Stridor）是極其嚴重的呼吸道警訊。這通常由喉頭水腫、出血導致的血腫壓迫，或雙側喉返神經受損引起。護理師在發現喉鳴的瞬間，必須假設呼吸道即將完全阻塞，優先準備緊急氣管切開包（Tracheostomy tray）或插管設備，並立即呼叫醫療團隊。這是 ABC 評估（Airway, Breathing, Circulation）中 Airway 的最高優先級處理。
Laryngeal stridor after thyroidectomy indicates upper airway obstruction, often due to edema or hematoma, which is a life-threatening emergency. The nurse must prioritize securing the airway by preparing for an emergency tracheostomy or intubation, as this addresses the immediate threat to breathing.