— 降低風險 · MEDIUM · MCQ —
護理師照護一位甲狀腺切除術後病人，下列哪項發現應優先處理，視為危及生命的併發症？
A nurse is caring for a client who is postoperative following a thyroidectomy. Which finding should the nurse prioritize as an indication of a life-threatening complication?
- AThe client has a noisy, high-pitched crowing sound during inspiration.✓ 正解病人在吸氣時發出嘈雜、高音調的喘鳴聲。
- BThe client has a small amount of serosanguineous drainage on the dressing.病人敷料上有少量血清血性引流液。
- CThe client is unable to speak clearly due to hoarseness.病人因聲音沙啞而無法清楚說話。
- DThe client reports a sore throat when swallowing.病人報告吞嚥時喉嚨痛。
— Explanation · 中文詳解 —
甲狀腺術後最嚴重併發症為喉頭水腫或出血壓迫氣管，造成呼吸道阻塞。高頻吸氣音（stridor）代表氣道狹窄，屬於呼吸道急症，必須立即通知醫療團隊並備妥插管工具。其餘選項分別為術後常見預期反應或較輕微的併發症，危險性較低。
Stridor, a noisy high-pitched crowing sound during inspiration, indicates airway obstruction from laryngeal edema or hematoma, which is a life-threatening emergency after thyroidectomy. This finding takes priority over expected minor drainage, hoarseness, or sore throat, as it requires immediate intervention to secure the airway.
✦ 台美臨床差異
美國護理師常執行床邊氣道評估並啟動快速反應小組；台灣護理師多需醫師判定後方執行進一步處置。