— 降低風險 · HARD · MCQ —
一位病人剛完成甲狀腺切除術。以下哪個評估結果需要最立即的處理？
A nurse is caring for a client who has just returned from a thyroidectomy. Which assessment finding requires the most immediate action?
- AHoarseness when speaking說話時聲音沙啞
- BStridor and high-pitched respiratory sounds✓ 正解喘鳴和高調呼吸音
- CPatient complains of a sore throat when swallowing病人主訴吞嚥時喉嚨痛
- DIncisional dressing with serosanguineous drainage切口敷料有血清血性滲出液
— Explanation · 中文詳解 —
甲狀腺術後最致命的併發症為氣道阻塞。喘鳴聲（Stridor）代表喉頭水腫或聲帶麻痺導致的呼吸道狹窄，若不緊急處理將導致窒息。其他選項如喉嚨痛、聲音沙啞為術後常見預期反應，傷口少量血清滲液則為正常現象，無需立即干預。
Stridor indicates upper airway obstruction, often caused by laryngeal edema or hematoma compression following thyroidectomy, which is a life-threatening emergency. Immediate action is required to secure the airway, whereas hoarseness and mild soreness are expected postoperative findings.
✦ 台美臨床差異
美國護理師常備有急救插管盤在病房；台灣則多由麻醉科醫師或耳鼻喉科醫師立即介入處理。