— 降低風險 · HARD · MCQ —
一位甲狀腺切除術後 4 小時的病人出現喉鳴音及呼吸窘迫。護理師的首要行動為何？
A nurse is assessing a client 4 hours post-thyroidectomy. The client exhibits laryngeal stridor and respiratory distress. What is the nurse's priority action?
- APosition the client flat將病人置於平臥位
- BContact the rapid response team✓ 正解聯繫快速反應小組
- CObtain an oxygen saturation reading測量血氧飽和度
- DAdminister IV calcium gluconate靜脈注射葡萄糖酸鈣
— Explanation · 中文詳解 —
甲狀腺切除術後發生喉鳴音（stridor）通常指向急性喉頭水腫或術後出血壓迫氣管，這是威脅生命的緊急狀況，必須立即啟動快速反應小組（RRT）或通知麻醉科醫師準備氣管插管。此時維持呼吸道通暢是最高指導原則，不應浪費時間在非緊急的處理上。
Laryngeal stridor and respiratory distress four hours post-thyroidectomy suggest acute airway compromise, likely from edema or hematoma, which is a life-threatening emergency. The nurse's priority is to activate the rapid response team immediately to secure the airway, rather than delaying for monitoring or administering medications for unrelated conditions.
✦ 台美臨床差異
美國護理師對緊急氣道問題啟動 RRT 流程相當成熟；台灣則是呼叫相關科別醫師（如耳鼻喉科或外科）處理。