— 降低風險 · HARD · MCQ —
護理師照護一位剛完成甲狀腺切除術的病人，發現病人出現喘鳴聲且說話困難。下列哪項措施為優先？
A nurse is caring for a client who has just returned from a thyroidectomy. The nurse notes the client has developed stridor and has difficulty speaking. Which of the following is the priority intervention?
- APerform a neurological assessment進行神經學評估
- BNotify the surgeon immediately for potential airway obstruction✓ 正解立即通知外科醫師以排除潛在氣道阻塞
- CElevate the head of the bed to 45 degrees將床頭抬高至 45 度
- DAdminister IV calcium gluconate給予靜脈注射葡萄糖酸鈣
— Explanation · 中文詳解 —
甲狀腺切除術（Thyroidectomy）後，頸部區域的出血或血腫（Hematoma）可能迅速壓迫氣管，導致呼吸道阻塞。喘鳴聲（Stridor）是氣道受阻的危急徵象，說話困難則暗示喉返神經受損或腫脹壓迫。此狀況屬於生命威脅，必須立即通報外科醫師進行緊急氣道評估與處理。這是護理師在術後照護中最需高度警覺的緊急情境。
Stridor and difficulty speaking after a thyroidectomy indicate a potential airway emergency caused by hematoma or edema compressing the trachea. The priority intervention is to notify the surgeon immediately for urgent assessment and intervention to secure the airway.