— 照護管理 · MEDIUM · SATA —
下列哪些行為展現了護理師適當的優先順序評估？（選所有適合的）
Which of the following actions by a nurse demonstrates appropriate prioritization of care? (Select all that apply.)
- AAssessing the client with tachycardia before passing medications to stable clients✓ 正解在將藥物遞送至穩定病人之前，先評估心跳過速的病人
- BPrioritizing an unstable client over a client awaiting discharge✓ 正解優先處理不穩定病人，而非等待出院的病人
- CDelegating the bed bath of a stable client to a UAP✓ 正解將穩定病人的擦澡工作委派給未註冊護理人員 (UAP)
- DDocumenting care before assessing the client with chest pain在評估胸痛病人之前先記錄照護內容
- ECompleting a sterile dressing change before doing a non-urgent admission assessment✓ 正解在進行非緊急入院評估之前，完成無菌換藥
— Explanation · 中文詳解 —
護理師需區分急迫性。心跳過速、不穩定病人為高優先級。下放非侵入性照護給 UAP 符合效率原則。相較於無急迫性的行政評估，無菌技術與換藥應先完成。D 為錯誤順序，病人狀態危急時必須先進行評估與護理，文件紀錄是次要的。
Nursing prioritization requires distinguishing between urgent clinical needs and routine tasks. Unstable clients, such as those with tachycardia or awaiting discharge from critical care, take precedence over stable patients. Delegating non-invasive care to UAPs and completing sterile procedures before non-urgent assessments ensures efficient resource use and maintains patient safety standards.
✦ 台美臨床差異
兩地均強調 ABC 與 Safety First 準則，但在文件紀錄（Charting）壓力上，台灣護理師常需被迫在忙碌中進行文書作業，與臨床優先級衝突較大。