— 降低風險 · HARD · MCQ —
護理師照護一位甲狀腺切除術後病人，發現病人說話時出現喉鳴音（stridor）。護理師應優先採取哪項措施？
A nurse is caring for a client who is postoperative following a thyroidectomy. The nurse notes laryngeal stridor when the client speaks. Which action is the priority?
- APerform a neurological assessment執行神經系統評估
- BCall for assistance and notify the surgeon✓ 正解尋求協助並通知外科醫師
- CAdminister an analgesic for pain給予止痛藥以緩解疼痛
- DPrepare for immediate intubation準備立即進行氣管插管
— Explanation · 中文詳解 —
甲狀腺切除術（Thyroidectomy）後，喉鳴音（Stridor）是氣道阻塞的警訊。這可能是由於手術部位術後出血（Hematoma）壓迫氣管，或是喉返神經受損導致聲帶麻痺，亦可能是喉水腫所致。此為危及生命的急症，護理師的首要任務是確保氣道通暢，必須立即呼叫協助並通知醫師，以準備進行緊急處置或插管。
Laryngeal stridor following a thyroidectomy indicates potential airway compromise due to edema, hematoma, or vocal cord paralysis, which is a life-threatening emergency. The nurse must immediately call for assistance and notify the surgeon to prepare for urgent interventions such as intubation or surgical decompression.
✦ 台美臨床差異
在美國術後照護中，此類病人通常會被置於急救設備齊全的病房，且隨時備有氣切盤（Tracheostomy tray）在床邊，護理師必須熟悉 Rapid Response Team（快速反應團隊）的啟動機制。