— 照護管理 · HARD · MCQ —
護理師擔任急診檢傷官，哪位病人應優先處理？
A nurse is triage officer in an emergency department. Which client should be seen first?
- AA client with history of asthma reporting chest tightness and wheezing✓ 正解有氣喘病史，主訴胸部緊縮與喘鳴的個案
- BA client with a closed fracture of the humerus complaining of severe pain肱骨閉合性骨折，抱怨劇烈疼痛的個案
- CA client with nausea and vomiting for 24 hours presenting with dizziness噁心嘔吐 24 小時並伴隨頭暈的個案
- DA client with a superficial laceration of the forehead actively bleeding額頭表淺撕裂傷且持續出血的個案
— Explanation · 中文詳解 —
根據 ABC（呼吸、呼吸道、循環）原則，呼吸問題是致命的。氣喘發作若出現呼吸喘鳴（Wheezing）與胸悶，顯示支氣管痙攣與氧氣交換障礙，隨時可能呼吸衰竭，故優先級最高。骨折、輕微撕裂傷、脫水雖需處理，但均無立即危及生命風險。
The client with asthma experiencing chest tightness and wheezing should be seen first because these symptoms indicate a potential airway obstruction and imminent respiratory failure. According to ABC principles, maintaining a patent airway and adequate breathing takes precedence over pain management or fluid replacement.
✦ 台美臨床差異
美國急診檢傷（ESI）系統高度標準化；台灣急診檢傷標準化程度提升，但仍受病患家屬壓力影響執行順序。