甲狀腺切除術後 12 小時。病人出現粗糙、高頻的呼吸音（喘鳴音）。護理師的優先行動為何？
A client is 12 hours postoperative after a thyroidectomy. The client develops a harsh, high-pitched respiratory sound (stridor). What is the nurse's priority action?
- APrepare for emergency intubation or tracheostomy✓ 正解準備緊急氣管插管或氣管切開術
- BCheck the client's temperature檢查病人的體溫
- CAdminister an oral analgesic給予口服止痛藥
- DEncourage the client to cough and deep breathe鼓勵病人咳嗽和深呼吸
甲狀腺切除術 (thyroidectomy) 後，病人有潛在的氣道阻塞風險，這是一種需要立即處理的危急情況。手術部位的水腫、血腫形成壓迫氣管，或喉返神經 (recurrent laryngeal nerve) 損傷導致聲帶麻痺，都可能造成上呼吸道阻塞。 喘鳴音 (stridor) 是一種粗糙、高頻的吸氣音，是上呼吸道阻塞的典型且嚴重的臨床徵象，表示氣流通過狹窄的氣道時產生湍流。一旦病人出現喘鳴音，護理師必須立即將其視為呼吸道緊急事件，因為這可能迅速進展為完全性氣道阻塞，危及生命。因此，護理師的首要行動是立即準備緊急氣道重建，如氣管插管 (intubation) 或氣管切開術 (tracheostomy)，確保病人的呼吸暢通。這符合臨床判斷中的 ABC (Airway, Breathing, Circulation) 原則，氣道安全永遠是最高的優先級。 其他選項的處置則無法解決氣道阻塞的緊急問題。
After thyroidectomy, the client has a potential risk for airway obstruction, an emergency that must be addressed immediately. Edema at the surgical site, hematoma compressing the trachea, or recurrent laryngeal nerve injury causing vocal cord paralysis can all cause upper airway obstruction. Stridor is a harsh, high-pitched inspiratory sound and a classic and serious sign of upper airway obstruction, produced as airflow becomes turbulent through a narrowed airway. Once stridor occurs, the nurse must treat it as an airway emergency because it can quickly progress to complete obstruction and become life-threatening. Therefore, the nurse's priority action is to immediately prepare for emergency intubation or tracheostomy to secure the airway. This aligns with the ABC (Airway, Breathing, Circulation) priority framework in which airway safety is always the highest priority. The other options do not address the airway emergency.