在聽取完床邊交班後，急性照護護理師必須安排巡房的優先順序。護理師必須「立即」評估下列哪一位病患？
After receiving the bedside shift report, an acute care nurse must prioritize rounding. Which patient must the nurse assess IMMEDIATELY?
- AA 45-year-old with liver cirrhosis who just vomited a large amount of bright red blood with a heart rate of 118 bpm.✓ 正解一位45歲患有肝硬化且剛嘔吐大量鮮紅血液、心率为118次/分的患者。
- BA 77-year-old with a urinary tract infection with cloudy urine and a fever of 38.5°C (101.3°F) awaiting initial IV antibiotics.一位77歲患有尿路感染、尿液渾濁且體溫38.5°C（101.3°F），正等待首次靜脈注射抗生素的患者。
- CA 58-year-old receiving a continuous heparin infusion for a deep vein thrombosis complaining of 5/10 aching leg pain.一位58歲因深部靜脈血栓接受連續肝素輸注，主訴腿部酸痛程度為5/10的患者。
- DA 32-year-old with asthma exhibiting scattered high-pitched wheezing, respiratory rate 24/min, awaiting a scheduled nebulizer treatment.一位32歲患有氣喘，聽診有散在的高調哮鳴音、呼吸頻率24次/分，正等待scheduled霧化治療的患者。
本題測驗 Prioritization (優先順序) 的 ABC (呼吸道、呼吸、循環) 評估原則。在評估這四位病患時，護理師必須尋找面臨最急迫生命威脅的人。選項A的肝硬化病患突然嘔吐大量鮮血，極度懷疑為食道靜脈曲張破裂（Esophageal Varices Rupture）。這屬於致死性的巨大出血，不僅會立即導致出血性休克（心跳已達 118 次/分，顯示代償性心衰竭或失血徵兆），且大量血液極易吸入氣管導致窒息，同時威脅了 Airway 與 Circulation，必須優先急救。選項D氣喘的散在性喘鳴與 RR 24 雖須處理，但在此時仍屬穩定；選項C的腿痛為 DVT 的典型不適；選項B發燒與濁尿為 UTI 預期表現，未呈休克。
The nurse must immediately assess the client with liver cirrhosis vomiting bright red blood, as this suggests ruptured esophageal varices causing life-threatening hemorrhage and potential airway compromise. This condition poses an immediate threat to circulation and airway, whereas the other clients exhibit stable or expected findings for their respective conditions.
台灣與美國在急性照護的評估優先順序上完全吻合，皆採納心肺生命維持法規中 ABC 凌駕一切的基本原則。