— 降低風險 · HARD · MCQ —
護理師照護一位剛進行甲狀腺切除術的病人，發現病人出現喘鳴（stridor）。下列何者為優先措施？
A nurse is caring for a client who has just returned from a thyroidectomy. The nurse notes the client is exhibiting stridor. Which action is the priority?
- APlace the client in high-Fowler's position將病人置於高福勒氏臥位
- BNotify the surgeon immediately立即通知外科醫師
- CPrepare for emergency tracheostomy✓ 正解準備緊急氣管切開術
- DAdminister pain medication給予止痛藥
— Explanation · 中文詳解 —
甲狀腺切除術後，病人出現喘鳴（Stridor）是呼吸道阻塞的危急徵象。這通常是由於術後喉頭水腫（Laryngeal edema）、出血壓迫氣管，或喉返神經受損導致聲帶麻痺所致。此情況可能迅速惡化為呼吸道完全阻塞，護理師必須立刻準備急救氣道設備（如氣管切開包 Tracheostomy kit），並通知外科醫師立即處置，這屬於緊急狀態。
Stridor indicates a critical airway obstruction, likely due to laryngeal edema or hematoma post-thyroidectomy. The nurse must prioritize preparing for an emergency tracheostomy to secure the airway rather than positioning or administering pain medication.