— 照護管理 · HARD · SATA —
交班時，護理師應優先評估下列哪些病人？（選所有適合的）
Which clients should the nurse prioritize to see first during the shift? (Select all that apply.)
- AA patient with stable chest pain post-nitroglycerin administration硝酸甘油給藥後胸痛穩定的病人
- BA patient reporting sudden onset of shortness of breath✓ 正解主訴突然發作呼吸困難的病人
- CA patient with a new change in level of consciousness✓ 正解意識水準發生新變化的病人
- DA patient scheduled for routine wound dressing change預約常規傷口換藥的病人
- EA patient with a drop in blood pressure from 130/80 to 90/50 mmHg✓ 正解血壓從 130/80 降至 90/50 mmHg 的病人
— Explanation · 中文詳解 —
護理師優先順序遵循 ABC（呼吸道、呼吸、循環）原則及病況改變的急迫性。突然呼吸困難（B）、意識改變（C）及血壓大幅下降（E）均為威脅生命的緊急狀況，必須優先處理。A 為穩定病患，D 為常規照護，優先順序較後。
The nurse should prioritize clients with acute respiratory distress, sudden changes in level of consciousness, and significant hypotension, as these indicate life-threatening instability requiring immediate intervention. Stable chest pain and routine wound care are lower priorities compared to these urgent physiological threats.
✦ 台美臨床差異
臨床優先順序（Prioritization）邏輯在台美教育中高度相似，但台灣護理師可能因照顧床數較多，更需精確的評估技巧以快速篩選病人。