— 降低風險 · MEDIUM · MCQ —
護理師照護一位甲狀腺切除術後剛返室的病人。下列哪項發現是護理師需優先監測的？
A nurse is caring for a client who has returned to the unit following a thyroidectomy. Which of the following findings is the priority for the nurse to monitor?
- APresence of noisy respirations✓ 正解出現嘈雜的呼吸聲
- BPain level at the incision site切口處的疼痛程度
- CDrainage on the dressing敷料上的引流液
- DAbility to speak clearly清晰說話的能力
— Explanation · 中文詳解 —
甲狀腺切除術（Thyroidectomy）後，護理師首要監測的是氣道通暢度（Airway）。由於手術部位靠近氣管，術後常見併發症包括血腫壓迫或喉頭水腫（Laryngeal edema）。呼吸音嘈雜（如喘鳴音 Stridor）是氣道阻塞的危急徵兆，若不及時處理可能導致氣道完全封閉。依據 ABC（Airway, Breathing, Circulation）原則，這是必須立即處理的優先事項。
Noisy respirations, such as stridor, indicate potential airway obstruction due to laryngeal edema or hematoma, which are life-threatening emergencies following a thyroidectomy. According to the ABC (Airway, Breathing, Circulation) priority framework, maintaining a patent airway is the nurse's most critical responsibility.