— 降低風險 · HARD · MCQ —
護理師照護一位剛進行甲狀腺切除術的病人，發現頸部腫脹且出現哮鳴音（stridor）。護理師應優先採取哪項措施？
A nurse is caring for a client who has just returned from a thyroidectomy. The nurse notes the client has developed stridor and swelling around the neck. Which action is the priority?
- AApply an ice pack to the neck incision在頸部切口處冰敷
- BElevate the head of the bed to 45 degrees將床頭抬高至45度
- CPrepare for emergency tracheostomy✓ 正解準備緊急氣管切開術
- DAdminister IV calcium gluconate靜脈注射葡萄糖酸鈣
— Explanation · 中文詳解 —
甲狀腺術後呼吸道阻塞是致命併發症。哮鳴音代表氣道受壓迫，通常由血腫或喉頭水腫引起，必須立即建立人工氣道以維持呼吸。抬高床頭僅能緩解，不能解決梗塞；鈣劑用於治療低血鈣抽搐，非首要急救；冰敷僅能緩解發炎，緩不濟急。
Stridor following a thyroidectomy indicates acute airway compromise, often due to hematoma or laryngeal edema, which is a life-threatening emergency. The nurse must prioritize preparing for an emergency tracheostomy or airway intervention to restore breathing. Other measures like elevating the head or applying ice are insufficient to address this critical obstruction.
✦ 台美臨床差異
美國護理師在緊急時需協助準備氣切套管或插管設備；台灣護理師亦同，但氣切執行權限嚴格限制於麻醉科或耳鼻喉科醫師。