— 降低風險 · HARD · MCQ —
護理師照護一位剛進行甲狀腺切除術的病人。哪項評估發現需要護理師立即注意？
A nurse is caring for a client who has just returned from a thyroidectomy. Which assessment finding requires the nurse's immediate attention?
- ARespiratory rate of 24 breaths/min with stridor✓ 正解呼吸頻率 24 次/分並伴有喘鳴音
- BDrainage on the dressing of 2 cm敷料上有 2 cm 的滲出液
- CPatient complains of a sore throat病人抱怨喉嚨痛
- DPatient is drowsy but awakens to voice病人嗜睡但對聲音有反應
— Explanation · 中文詳解 —
甲狀腺切除術後氣管受壓或喉神經受損是致命風險。喘鳴音（stridor）為氣道狹窄的徵兆，可能導致氣道梗塞，屬 ABC 優先級中最迫切的呼吸道問題。其他選項如喉嚨痛為常見術後症狀，小量滲血或輕微嗜睡均在術後恢復期的預期範圍內。
Stridor indicates upper airway obstruction, which is a life-threatening emergency requiring immediate intervention post-thyroidectomy. While sore throat, minor drainage, and drowsiness are expected findings due to intubation and anesthesia, airway patency takes priority under the ABC framework.
✦ 台美臨床差異
美台臨床皆視 stridor 為緊急，但美國護理師常需直接準備氣管內插管組，台灣則多先呼叫麻醉科與外科醫師協助評估。