— 照護管理 · HARD · MCQ —
護理師同時照顧四位病人，哪一位應優先處理？
A nurse is caring for four clients. Which client should the nurse see first?
- AA client with a history of asthma who is experiencing increased dyspnea and accessory muscle use✓ 正解有氣喘病史且出現呼吸困難增加及使用輔助呼吸肌的病人
- BA client with a Foley catheter who is requesting assistance to ambulate to the bathroom有導尿管且請求協助走到浴室的病人
- CA client with type 1 diabetes reporting a blood glucose of 140 mg/dL報告血糖為 140 mg/dL 的第一型糖尿病病人
- DA client 2 days postoperative who is reporting pain level 6/10術後兩天且報告疼痛程度為 6/10 的病人
— Explanation · 中文詳解 —
依據 ABC（氣道、呼吸、循環）優先順序原則，呼吸困難且出現輔助肌使用，顯示病人處於急性呼吸窘迫狀態，可能隨時惡化為呼吸衰竭，故需立即介入。其餘病人狀況如血糖偏高、疼痛、協助走動均為次要或穩定需求，不具立即致命性。
Using the ABC (Airway, Breathing, Circulation) framework, the client with asthma showing accessory muscle use is experiencing an acute respiratory crisis that requires immediate intervention. This potential respiratory failure takes priority over stable conditions like mild hyperglycemia, manageable pain, or routine ambulation assistance.
✦ 台美臨床差異
在兩地臨床執業中，優先順序原則（Triage）皆遵循 ABC 原則，此為國際護理考試的核心共識。