一位外科護理師接收了一名剛完成部分甲狀腺切除術、從恢復室送來的病患。安置於病房後十五分鐘，病患突然出現大聲、高亢的吸氣性噪音。哪項行動代表護理師最關鍵的立即優先任務？
An experienced surgical nurse receives a client arriving directly from the Post-Anesthesia Care Unit (PACU) following a partial thyroidectomy. Fifteen minutes after settling the client into the room, the client develops sudden, noisy, high-pitched inspiratory sounds. Which action represents the most critical immediate priority for the nurse?
- AAdminister the prescribed PRN dose of IV morphine to calm the client.給予處方 PRN 劑量的靜脈注射嗎啡以安撫患者。
- BNotify the rapid response team and prepare a tracheostomy tray at the bedside.✓ 正解通知快速反應小組並在床邊準備氣管切開術器械。
- CInstruct the client to cough vigorously to clear the throat.指導患者用力咳嗽以清除喉嚨。
- DAssess the incisional dressing site specifically for a small amount of capillary oozing.特別檢查切口敷料是否有少量毛細血管滲血。
本題測驗甲狀腺手術致命併發症。甲狀腺切除術後若出現突發的『高亢吸氣頸鳴音 (stridor)』，這代表頸部正在因為血腫壓迫或聲門水腫導致致命性的氣管完全阻塞 (Airway emergency)。這病患數分鐘內就會窒息死亡。護理師絕對第一優先是啟動急救團隊 (Rapid response) 並立刻將氣切包 (Tracheostomy tray) 放置於床邊以備緊急氣管切開。
Sudden inspiratory stridor after a thyroidectomy indicates a life-threatening airway emergency, likely caused by a hematoma compressing the trachea or laryngeal edema. The nurse must immediately notify the rapid response team and prepare a tracheostomy tray at the bedside to facilitate an emergency airway opening.
甲狀腺切除術後三大致命考驗：Stridor(查氣切包)、Hypocalcemia(查低血鈣)、Hemorrhage(頸後積血)。聽到 Stridor 是絕對的 Airway 第一順位。