— 降低風險 · MEDIUM · MCQ —
一位病人剛完成甲狀腺切除手術，護理師應優先評估哪項發現？
A nurse is caring for a client who has just returned from a thyroidectomy. Which assessment finding should the nurse prioritize?
- AStridor and difficulty breathing✓ 正解喘鳴和呼吸困難
- BPatient complains of a hoarse voice when speaking病人抱怨說話時聲音沙啞
- CIncision site dressing shows a small amount of serosanguineous drainage切口處敷料顯示少量漿血性滲出液
- DPatient reports pain at the surgical site rated 4/10病人報告手術部位疼痛程度為4/10
— Explanation · 中文詳解 —
甲狀腺切除術後呼吸道通暢是最高優先級。喘鳴音（Stridor）暗示喉頭水腫或喉返神經受損，若未立即處理可能導致氣道完全阻塞。聲帶功能變化或引流液屬於重要觀察，但與呼吸窘迫相比，維持氣道通暢為生命安全之首要任務。
The nurse should prioritize assessing for stridor and difficulty breathing, as these are signs of airway obstruction that constitute an immediate medical emergency. Post-thyroidectomy airway compromise can result from laryngeal edema or hemorrhage, which can rapidly lead to asphyxiation. While hoarseness and minor drainage are expected findings, they do not pose the same immediate threat to life as airway obstruction.
✦ 台美臨床差異
美台臨床皆視喘鳴音為外科急症；在台灣，此類病人通常置於 ICU 密切監測，美國則依術後復原路徑於病房監控。