— 照護管理 · MEDIUM · MCQ —
護理師正在進行交班報告，哪位病人應優先評估？
A nurse is receiving a change-of-shift report for four clients. Which client should the nurse see first?
- AA client with a fever of 101.2°F (38.4°C) and stable vital signs體溫 101.2°F（38.4°C）且生命徵象穩定的病人
- BA client with asthma who reports a wheezing episode 4 hours ago✓ 正解四小時前報告有哮鳴發作的氣喘病人
- CA client with a new diagnosis of diabetes mellitus waiting for discharge education新診斷糖尿病且等待出院衛教的病人
- DA client with a hip replacement reporting pain at 4 on a 0-10 scale主訴疼痛指數為 4 分（0-10 分制）的髖關節置換術後病人
— Explanation · 中文詳解 —
NCLEX 優先順序題（Prioritization）的核心是 ABC 原則（Airway, Breathing, Circulation）。氣喘雖為 4 小時前發作，但氣喘具有高度「不可預測性」，隨時可能惡化為呼吸衰竭，故需優先評估其目前的呼吸狀況、有無呼吸音異常或呼吸費力。疼痛與發燒雖需處理，但屬於穩定病況。
Apply the ABC (Airway, Breathing, Circulation) prioritization framework, where respiratory status takes precedence over other concerns. Although the wheezing occurred four hours ago, asthma is unpredictable and can rapidly deteriorate into respiratory failure, requiring immediate assessment of current breathing patterns and lung sounds.