— 安全與感染控制 · HARD · MCQ —
護理師交班後，應優先評估哪位病人？
Which client should the nurse assess first when receiving the shift report?
- AA client with a new onset of respiratory stridor✓ 正解新出現喘鳴聲的病人
- BA client complaining of mild nausea after breakfast早餐後抱怨輕微噁心的病人
- CA client awaiting discharge papers for two hours等待出院文件兩小時的病人
- DA client with a wound dressing that is slightly blood-stained傷口敷料略帶血漬的病人
— Explanation · 中文詳解 —
在交班評估中，必須根據 ABC（氣道、呼吸、循環）優先順序判斷。呼吸道狹窄（Stridor）暗示氣道遭到阻塞或腫脹，屬於極高危險的氣道緊急狀況（Airway Emergency），若不立即處理，隨時會進展至氣道完全閉鎖而導致窒息。相比之下，其他選項如輕微出血、噁心或等待出院，皆屬於穩定狀況，無即刻生命危險，因此必須優先評估該名呼吸窘迫的病人。
The nurse must prioritize assessment based on the ABC (Airway, Breathing, Circulation) framework. New-onset respiratory stridor indicates potential airway obstruction or swelling, which is a life-threatening emergency requiring immediate intervention to prevent asphyxiation. Other options, such as mild nausea, slight wound drainage, or discharge delays, represent stable conditions without imminent threat to life.