— 降低風險 · HARD · MCQ —
護理師照護一位術後 2 小時的甲狀腺切除術病人，發現病人出現喉部喘鳴（laryngeal stridor）。何者為優先處置？
A nurse is caring for a client who is 2 hours post-thyroidectomy. The nurse notes the client is experiencing laryngeal stridor. Which action is the priority?
- ACheck the client's serum calcium levels檢查病人的血清鈣濃度
- BPlace the client in a high-Fowler's position將病人置於高福勒氏臥位
- CPrepare for immediate intubation✓ 正解準備立即插管
- DAdminister an analgesic for incision pain給予切口疼痛的止痛藥
— Explanation · 中文詳解 —
喉部喘鳴（Laryngeal stridor）是甲狀腺切除術後最嚴重的併發症預兆，通常暗示喉頭水腫、聲帶麻痺或因血腫壓迫氣管。氣道安全（Airway）是護理的首要考量。喘鳴音預示即將發生的氣道完全阻塞，護理師必須立即準備建立人工氣道（如插管）並通知外科醫師。不可等待或嘗試給予止痛藥，因為這是在處理病人生命威脅的關鍵時刻。
Laryngeal stridor after thyroidectomy indicates a potential airway emergency caused by laryngeal edema, hematoma, or nerve damage. Because airway patency is the highest priority, the nurse must prepare for immediate intubation to prevent respiratory arrest. Other interventions, such as checking calcium levels or administering analgesics, do not address the immediate threat to the airway.