— 降低風險 · HARD · MCQ —
一位病人於甲狀腺切除術後 2 小時，突然出現喘鳴聲。護理師應採取哪項優先措施？
A nurse is caring for a client who is 2 hours post-operative after a thyroidectomy. The client suddenly develops stridor. Which action is the priority?
- AAdminister IV calcium gluconate靜脈注射葡萄糖酸鈣
- BPlace the client in semi-Fowler's position將病人置於半坐臥位
- CAssess the surgical dressing for bleeding評估手術敷料是否有出血
- DPrepare for emergency tracheostomy✓ 正解準備緊急氣管造口術
— Explanation · 中文詳解 —
甲狀腺切除術後，病人出現喘鳴聲（Stridor）是呼吸道阻塞的緊急徵兆，通常起因於喉頭水腫（Laryngeal edema）、出血壓迫或喉返神經受損導致的聲帶麻痺。這是生命危險的緊急情況，護理師應評估後立即通知醫師，並準備緊急氣管切開術（Emergency tracheostomy）設備，以備呼吸道完全阻塞時進行緊急插管或造口，確保氧氣流通。
Stridor following a thyroidectomy is a critical sign of airway obstruction, often caused by laryngeal edema or hemorrhage compressing the trachea. Because this represents an immediate threat to life, the nurse must prioritize preparing for an emergency tracheostomy to secure the airway rather than performing less urgent assessments.