— 照護管理 · MEDIUM · MCQ —
護理師照顧一群病人，哪一位應優先被查看？
A nurse is caring for a group of clients. Which client should be seen first?
- AA client with a newly placed chest tube reporting localized pain剛置入胸管並報告局部疼痛的病人
- BA client with a soft-tissue injury reporting itching under the cast軟組織受傷並報告石膏下有搔癢感的病人
- CA client with chronic rheumatoid arthritis needing morning medication患有慢性類風濕性關節炎且需要晨間藥物的病人
- DA client with a history of heart failure reporting a 3-lb weight gain in 24 hours✓ 正解有心衰竭病史並報告 24 小時內體重增加 3 磅的病人
— Explanation · 中文詳解 —
心衰竭病人的體重快速增加是液體超載（Fluid Overload）的關鍵臨床指標。24 小時內增加 3 磅極可能表示急性失代償，需立即評估心肺狀態與利尿劑成效。相比之下，胸管部位局部痛屬於常見術後反應，風濕痛與石膏下癢感則不具立即生命威脅。
Rapid weight gain in a client with heart failure indicates fluid retention and potential pulmonary edema, which requires immediate assessment. While chest tube pain and itching under a cast are common complaints, they are not life-threatening emergencies compared to acute decompensation.
✦ 台美臨床差異
美國護理評估強調異常趨勢偵測；台灣臨床護理師常受限於常規作業時間，較難即時對微小異常進行優先排序。