— 照護管理 · EASY · MCQ —
護理師在忙碌的急診工作，哪位病人應優先處理？
A nurse is working in a busy emergency department. Which client should the nurse see first?
- AA client with a sudden onset of stridor and accessory muscle use✓ 正解突發性喘鳴音並使用輔助呼吸肌的病人
- BA client with a closed wrist fracture reporting pain 6/10報告疼痛程度為 6/10 的閉合性手腕骨折病人
- CA client with type 2 diabetes who has a blood glucose of 180 mg/dL血糖為 180 mg/dL 的第二型糖尿病病人
- DA client with a superficial laceration requiring sutures需要縫合的淺層撕裂傷病人
— Explanation · 中文詳解 —
根據檢傷分類與 ABC 原則，呼吸道通暢是生命維持的第一優先。喘鳴音（Stridor）代表呼吸道出現阻塞，伴隨呼吸輔助肌使用顯示呼吸窘迫已達嚴重程度，若不立即介入，隨時可能導致窒息與呼吸停止，必須立即優先處置。
According to triage principles and the ABC (Airway, Breathing, Circulation) framework, airway patency is the highest priority. Stridor indicates upper airway obstruction, and the use of accessory muscles signals severe respiratory distress. This client requires immediate intervention to prevent potential asphyxiation and respiratory arrest, making them the first priority over those with stable fractures, hyperglycemia, or minor lacerations.
✦ 台美臨床差異
美台兩地急診檢傷系統（如 ESI）標準一致，皆將呼吸窘迫列為等級一或二，需立即醫師評估。