— 生理適應 · HARD · MCQ —
甲狀腺切除術後的病人出現喉鳴音（laryngeal stridor），護理師應優先採取何種措施？
A nurse is caring for a client who is post-thyroidectomy. The client exhibits laryngeal stridor. Which action is the priority?
- AAlert the rapid response team and prepare for intubation✓ 正解通知快速反應團隊並準備插管
- BElevate the head of the bed to 45 degrees將床頭抬高至 45 度
- CCheck the surgical dressing for bleeding檢查手術敷料是否有出血
- DAdminister IV calcium gluconate靜脈注射葡萄糖酸鈣
— Explanation · 中文詳解 —
甲狀腺切除術後，喉鳴音（Laryngeal stridor）是極度危險的徵兆，通常提示喉頭水腫（Laryngeal edema）或術中損傷喉返神經（Recurrent laryngeal nerve）導致聲帶麻痺。這種狀況會迅速導致呼吸道阻塞，造成窒息。護理師的第一優先行動是立即啟動快速反應小組（Rapid Response Team），並準備氣道處置工具（如插管設備），以確保病人氣道暢通（Airway）。
Laryngeal stridor after thyroidectomy indicates potential airway obstruction due to laryngeal edema or recurrent laryngeal nerve damage, which is a medical emergency. The nurse's priority is to alert the rapid response team and prepare for intubation to secure the airway, as this takes precedence over other assessments or interventions.