— 照護管理 · MEDIUM · MCQ —
一位護理師正在接收入院一位有呼吸窘迫病史的病人。哪項措施是呼吸道管理的優先考量？
A nurse is admitting a client with a history of respiratory distress. Which action is a priority for airway management?
- AAssess the client's respiratory rate and effort.✓ 正解評估病人的呼吸頻率與努力程度
- BAdminister oxygen via nasal cannula.經鼻導管給予氧氣
- CEncourage coughing and deep breathing.鼓勵咳嗽與深呼吸
- DPosition the client in a semi-Fowler's or high-Fowler's position.將病人置於半福勒氏或高福勒氏體位
— Explanation · 中文詳解 —
呼吸窘迫的病人首要任務是評估呼吸道的通暢度與呼吸效能。根據護理過程（Nursing Process），在介入（Intervention）前必須先進行評估（Assessment）。觀察呼吸頻率、深度、使用輔助肌情況及血氧飽和度（SpO2），能讓護理師快速判斷呼吸窘迫的嚴重程度，並據此決定是否需要緊急醫療支援或調整給氧策略。
Assessing the client’s respiratory rate and effort is the first priority to determine the severity of respiratory distress and airway patency. According to the nursing process, assessment must precede interventions such as positioning or administering oxygen. This evaluation guides subsequent actions and ensures that the client receives appropriate, timely care based on their actual physiological status.