— 降低風險 · HARD · MCQ —
護理師照護一位甲狀腺切除術後 4 小時的病人，發現病人出現喘鳴聲 (stridor)。護理師的首要行動為何？
A nurse is caring for a client who is 4 hours post-thyroidectomy. The nurse notes the client has developed stridor. What is the nurse's priority action?
- ANotify the surgeon immediately for potential airway compromise✓ 正解立即通知外科醫師，以防氣道受阻
- BAdminister calcium gluconate IV靜脈注射葡萄糖酸鈣
- CPerform suctioning of the tracheobronchial tree進行氣管支樹抽吸
- DPlace the client in a high-Fowler's position將病人置於高福勒氏臥位
— Explanation · 中文詳解 —
甲狀腺切除術後出現喘鳴，表示喉頭水腫或血腫壓迫氣道，這是致命性的呼吸道阻塞徵象。應立即通知醫師準備緊急氣道處理（如重插管或移除敷料減壓）。採取坐姿雖有助呼吸，但無法解決氣道阻塞；靜脈注射鈣劑用於治療低血鈣性抽搐，非處置喘鳴的首選；抽吸無法緩解外壓性氣道阻塞。
Stridor after thyroidectomy indicates potential airway compromise due to laryngeal edema or hematoma, which is a medical emergency. The nurse must immediately notify the surgeon for urgent intervention to secure the airway.
✦ 台美臨床差異
美國醫院有緊急插管小組（RRT），台灣則通常立即通知值班住院醫師或主治醫師進行緊急處置。