— 照護管理 · HARD · SATA —
護理師在交班後應優先評估哪些病人？（選所有適合的）
A nurse is caring for multiple clients. Which client should the nurse see first after receiving report? (Select all that apply.)
- AA patient reporting sudden onset of shortness of breath✓ 正解主訴突發性呼吸困難的病人
- BA patient with a scheduled dressing change for a chronic wound慢性傷口scheduled換藥的病人
- CA patient post-op 2 hours with sudden hypotension and tachycardia✓ 正解術後 2 小時出現突發性低血壓和心跳過速的病人
- DA patient requesting an analgesic for mild pain請求給予輕微疼痛止痛藥的病人
- EA patient with a new order for an antibiotic to be started now有新開立抗生素医嘱需立即開始給藥的病人
— Explanation · 中文詳解 —
在災難大量傷患（Mass casualty）情境下，護理師應優先評估與處理急迫且危及生命的病人。呼吸困難（呼吸道/呼吸功能）與術後低血壓/心跳過速（循環功能）皆屬於 ABC 原則中的急迫狀況，需立即評估。慢性傷口換藥、輕微疼痛給藥與抗生素給予雖需執行，但均不具備即時生命威脅，應排在穩定病人之後處理。這是災難 triage 的基本邏輯。
The nurse must prioritize clients with immediate threats to airway, breathing, or circulation (ABCs). Sudden shortness of breath indicates respiratory compromise, while postoperative hypotension and tachycardia suggest potential hemorrhage or shock. These life-threatening conditions take precedence over routine care, mild pain, or non-urgent medication administration.