護理師評估甲狀腺切除術後 2 小時的病人，發現其呼吸有喘鳴聲且頻繁吞嚥。護理師首要行動為何？
A nurse is assessing a client who is 2 hours post-thyroidectomy. The client exhibits stridor and frequent swallowing. What is the priority nursing action?
- ACheck the surgical dressing for bleeding檢查手術敷料是否有出血
- BPerform a neurological assessment進行神經學評估
- CAdminister pain medication給予止痛藥物
- DPrepare for emergency airway management✓ 正解準備進行緊急呼吸道管理
甲狀腺切除術（Thyroidectomy）後，呼吸喘鳴（Stridor）是喉頭水腫或氣管受到血腫壓迫的徵兆，屬於危急狀況。頻繁吞嚥則暗示傷口內有持續出血且血液流向咽喉。此時 ABC 原則中 Airway 最優先，護理師需立即啟動緊急程序，準備插管器械或氣切包（Tracheostomy tray），預防窒息。
The priority nursing action is to prepare for emergency airway management because stridor indicates airway obstruction, likely due to laryngeal edema or a hematoma compressing the trachea. Frequent swallowing suggests ongoing bleeding into the throat, further compromising the airway. Maintaining a patent airway is the highest priority according to ABCs, superseding assessments of the dressing, neurological status, or pain management.
美國臨床環境中，術後病房通常會將氣切包（Tracheostomy tray）直接放置在術後病人床頭，這與台灣部分病房配置可能不同，需熟知此標準護理常規。