— 照護管理 · MEDIUM · MCQ —
護理師在急診進行檢傷分類，哪位病人應優先處理？
A nurse is triaging patients in an emergency department. Which patient should the nurse see first?
- AA client with a superficial laceration requiring sutures一位需要縫合的淺表傷口病人
- BA client with a history of asthma presenting with audible wheezing and dyspnea✓ 正解有氣喘病史且出現聽得見的哮鳴音與呼吸困難的病人
- CA client with a closed wrist fracture reporting 6/10 pain主訴疼痛 6/10 的閉鎖性手腕骨折病人
- DA client with a fever of 38.5°C and productive cough體溫 38.5°C 且有產痰性咳嗽的病人
— Explanation · 中文詳解 —
依照 ABC 原則，呼吸道與呼吸效率受損者優先。氣喘發作伴隨哮鳴音與呼吸困難，顯示呼吸道阻塞風險，可能迅速惡化導致呼吸衰竭。骨折與淺表傷口皆不立即危及生命；發燒病人雖需處置，但在無生命徵象不穩定狀況下，優先權次於呼吸窘迫者。
The nurse should see the client with a history of asthma presenting with audible wheezing and dyspnea first, as respiratory distress represents an immediate threat to airway and breathing according to ABC prioritization. This client is at risk for rapid deterioration into respiratory failure, whereas the other clients have conditions that are currently stable or non-life-threatening.
✦ 台美臨床差異
台美檢傷系統皆採用急診五級檢傷分類，強調呼吸與循環狀況為最高優先級。