— 降低風險 · HARD · MCQ —
一位甲狀腺切除術後剛返室的病人出現喘鳴（stridor）及吸氣時的高頻音。護理師應優先採取何種行動？
A nurse is caring for a client who has just returned from a thyroidectomy. The nurse notes the client is exhibiting stridor and a high-pitched sound on inspiration. Which action should the nurse take first?
- APlace the client in a semi-Fowler's position將病人置於半坐臥位
- BAdminister an analgesic for pain給予止痛藥以緩解疼痛
- CPrepare for immediate re-intubation or tracheostomy✓ 正解準備立即重新插管或氣管切開術
- DCheck the client's vital signs測量病人的生命徵象
— Explanation · 中文詳解 —
甲狀腺術後出現喘鳴，高度懷疑喉頭水腫或氣管受壓（出血血腫），這是危及生命的氣道阻塞徵兆。護理師必須立即呼叫急救小組，準備氣道建立工具，避免窒息死亡。此時 ABC 原則中氣道受損優先於生命徵象測量或給予藥物。
Stridor after a thyroidectomy indicates potential airway obstruction from laryngeal edema or hematoma, which is a life-threatening emergency. The nurse must prioritize securing the airway by preparing for immediate re-intubation or tracheostomy, as this takes precedence over positioning, pain management, or monitoring vital signs.
✦ 台美臨床差異
美國護理師受過 ACLS/BLS 強調氣道優先，台灣護理人員遇此狀況多需等待醫師進行處置，但護理師應同步準備搶救設備。