— 安全與感染控制 · HARD · MCQ —
交班後，護理師應優先評估哪位病人？
Which client should the nurse assess first after receiving the shift report?
- AA client with a fever of 101.2 F (38.4 C) awaiting blood cultures✓ 正解發燒 101.2 F (38.4 C)，等待血液培養結果的病人
- BA client with a new onset of sudden confusion and restlessness新發突然意識混亂且煩躁不安的病人
- CA client who is scheduled for a routine discharge in two hours預計兩小時後常規出院的病人
- DA client requesting pain medication for surgical site discomfort因手術傷口不適要求止痛藥的病人
— Explanation · 中文詳解 —
護理優先順序評估應遵循 ABC 原則（Airway, Breathing, Circulation）及「威脅生命」原則。發燒病人若正在等待血液培養（Blood culture），代表懷疑有敗血症（Sepsis），敗血症可能迅速惡化為感染性休克，需優先給予抗生素與評估，其危險程度高於其他穩定或僅有不適感的病人。
The client with a fever awaiting blood cultures requires immediate assessment because this presentation suggests potential sepsis, which can rapidly progress to life-threatening septic shock.