— 降低風險 · HARD · MCQ —
護理師照護一位甲狀腺切除術後 2 小時的病人，發現其出現喘鳴音且呼吸困難。護理師應採取的優先措施為何？
A nurse is caring for a client who is 2 hours post-operative after a thyroidectomy. The nurse notes the client is experiencing stridor and difficulty breathing. What is the priority nursing action?
- ACall the Rapid Response Team呼叫快速反應團隊
- BPlace the client in a high-Fowler's position將病人置於高福勒氏體位
- CPrepare for emergency tracheostomy✓ 正解準備緊急氣管切開術
- DAdminister an IV corticosteroid給予靜脈皮質類固醇
— Explanation · 中文詳解 —
甲狀腺切除術後若出現喘鳴音，代表可能有喉頭水腫或血腫壓迫氣道，這是致命性的急症。首要目標是維持呼吸道通暢，必須立即準備進行氣管切開或插管，並通知醫師。保持高半坐臥位可緩解水腫，但無法解決氣道機械性阻塞。
Stridor after a thyroidectomy indicates potential airway obstruction from edema or hematoma, which is a life-threatening emergency. The priority nursing action is to prepare for an emergency tracheostomy or intubation to secure the airway immediately.
✦ 台美臨床差異
台美醫療體系對於甲狀腺術後呼吸困難的處置皆採高度警覺，美國護理師常攜帶氣切盤在床邊，台灣則多強調第一時間呼叫麻醉科與外科醫師。