— 照護管理 · MEDIUM · MCQ —
交班後，護理師應該優先評估哪一位病人？
Which of the following clients should the nurse assess first after receiving the change-of-shift report?
- AA client asking for pain medication for a chronic back issue因慢性背部問題要求止痛藥的個案
- BA client who just returned from a diagnostic procedure with an unstable blood pressure✓ 正解剛從診斷程序返回且血壓不穩的個案
- CA client with a fever of 101.2°F (38.4°C) post-surgery術後體溫 101.2°F (38.4°C) 的個案
- DA client with a stable wound dressing that needs changing敷料穩定但需要更換的個案
— Explanation · 中文詳解 —
優先評估原則（Prioritization）重點在於病人的生理穩定度。剛從檢查室回來且血壓不穩定（Unstable BP）的病人，極可能出現出血、休克或反應不良的風險，屬於急重症且變化最不可測，必須第一時間觀察其血流動力學狀態。
Prioritization is based on physiological stability and the potential for rapid deterioration. A client returning from a diagnostic procedure with unstable blood pressure is at high risk for hemorrhage, shock, or other complications requiring immediate assessment. Other clients described have stable or routine needs that do not pose an immediate threat to life.
✦ 台美臨床差異
兩地護理師對於「不穩定生命跡象」的優先順序判定皆一致，這是 NCLEX 的核心考點。