— 降低風險 · HARD · MCQ —
一位甲狀腺切除術後 2 小時的病人，護理師觀察到其出現刺耳的高頻呼吸音。護理師應立即採取哪項行動？
A nurse is caring for a client who is 2 hours post-operative after a thyroidectomy. The nurse notes the client has developed a harsh, high-pitched respiratory sound. Which action should the nurse take immediately?
- AAdminister an analgesic for pain給予止痛藥
- BPerform an oral suctioning of secretions進行口腔抽吸分泌物
- CCheck the surgical dressing for bleeding檢查手術敷料是否有出血
- DPrepare for immediate tracheostomy or intubation✓ 正解準備立即氣管切開或插管
— Explanation · 中文詳解 —
此症狀提示喉頭水腫或喉返神經損傷導致呼吸道阻塞。甲狀腺術後呼吸道通暢為最高優先級，若出現喘鳴音，應立即準備氣道建立措施以防止窒息。A 藥物緩解無助於改善梗阻；C 檢查敷料是評估出血，次於呼吸道管理；D 抽痰可能加重水腫。
At four months of age, infants typically develop the ability to roll from front to back as neck muscles strengthen. Other milestones like sitting without support, pincer grasp, and assisted walking occur later, generally between six and twelve months of age.
✦ 台美臨床差異
美國護理師常受過氣道評估培訓以啟動急救團隊，台灣則通常先通知麻醉科或耳鼻喉科醫師處置。