甲狀腺切除術後 4 小時，護理師評估發現何者最需擔憂？
A nurse is assessing a client 4 hours after a thyroidectomy. Which assessment finding is most concerning?
- AThe client has a small amount of serosanguineous drainage on the dressing個案敷料上有少量漿液血性滲出液
- BThe client complains of pain at the incision site個案抱怨切口處疼痛
- CThe client is experiencing laryngeal stridor✓ 正解個案出現喉頭哮鳴音
- DThe client has a low-grade fever of 99.2°F個案有 99.2°F 的低燒
甲狀腺切除術後，護理師需高度警覺呼吸道併發症。喉部哮鳴（Laryngeal stridor）是一種高頻的呼吸音，暗示氣管受壓或喉頭水腫，屬於呼吸道阻塞的危險徵兆。術後 4 小時內若出現此症狀，可能源於術後出血形成血腫（Hematoma）壓迫氣管，或因手術引發的喉水腫。依據 ABC（Airway, Breathing, Circulation）原則，呼吸道安全是最高優先級，一旦發生哮鳴，必須立即準備緊急氣道處理設備並通知醫師，必要時需準備緊急氣管切開術（Tracheostomy）。
Laryngeal stridor is the most concerning finding as it indicates potential airway obstruction due to laryngeal edema or hematoma compression, which is a life-threatening emergency. Minor serosanguineous drainage, incision pain, and low-grade fever are expected postoperative findings that do not pose an immediate threat to the airway.
台美臨床對於此類術後併發症的處理思維一致。在美國，護理師需在床邊備妥氣切盤（Trach tray）是標準流程，確保發生呼吸道阻塞時能立即執行緊急措施。