— 降低風險 · HARD · MCQ —
護理師照護一位甲狀腺切除術後剛從恢復室轉回的病人。下列哪項評估為最高優先級？
A nurse is caring for a client who has just returned from the post-anesthesia care unit following a thyroidectomy. Which assessment is the highest priority?
- AMonitor blood pressure for hypertension監測血壓是否有高血壓現象
- BCheck the dressing for bleeding檢查敷料是否有出血
- CAssess the client's ability to speak評估病人的說話能力
- DAssess for signs of airway obstruction✓ 正解評估是否有氣道阻塞跡象
— Explanation · 中文詳解 —
甲狀腺切除術後最嚴重的急性併發症是氣道阻塞，原因包括手術部位血腫壓迫氣管、喉頭水腫或聲帶麻痺。因此，評估呼吸道通暢性（Airway patency）是術後評估的最高優先級。護理師必須觀察病人的呼吸型態、有無喘鳴音（Stridor）、發音是否沙啞，並監測手術部位有無腫脹或引流液異常。一旦發現氣道受壓迫徵兆，必須立即通知外科醫師並備好急救設備。
The highest priority after a thyroidectomy is assessing for airway obstruction, which is the most life-threatening complication. Causes include hematoma compression, laryngeal edema, or vocal cord paralysis. While monitoring blood pressure, checking dressings, and assessing speech are important, maintaining a patent airway takes precedence over other assessments.