— 照護管理 · HARD · MCQ —
護理師在急診進行檢傷分類，哪位病人應優先接受評估？
A nurse is triaging clients in the emergency department. Which client should be evaluated first?
- AA 40-year-old with a minor laceration requiring sutures一名需要縫合的小撕裂傷40歲患者
- BA 50-year-old complaining of chest pain and shortness of breath✓ 正解主訴胸痛和呼吸困難的50歲患者
- CA 30-year-old with abdominal pain for three days腹痛三天的30歲患者
- DA 25-year-old with a stable fracture of the ankle踝關節骨折穩定的25歲患者
— Explanation · 中文詳解 —
急診檢傷分類（Triage）依據 ABC 原則（呼吸、循環、氣道）判斷優先序。胸痛合併呼吸困難顯示可能為急性冠心症（ACS）或肺栓塞，具有隨時惡化為心跳停止的風險，屬『緊急（Emergent）』等級。其他選項如骨折、撕裂傷或慢性腹痛，在生命徵象穩定下，可歸類為『次緊急（Urgent）』或『非緊急（Non-urgent）』。
The nurse should evaluate the client with chest pain and shortness of breath first, as these symptoms suggest a life-threatening cardiac or pulmonary event such as acute coronary syndrome or pulmonary embolism. According to triage principles based on airway, breathing, and circulation (ABC), this client requires immediate attention to prevent potential cardiac arrest. Other clients with minor lacerations, stable fractures, or chronic abdominal pain are considered less urgent.