— 降低風險 · HARD · MCQ —
護理師評估甲狀腺切除術後 4 小時的病人，發現喉鳴音與呼吸窘迫。護理師應採取何項優先措施？
A nurse is assessing a client 4 hours post-thyroidectomy. The nurse notes laryngeal stridor and respiratory distress. What is the nurse's priority action?
- ANotify the surgeon immediately立即通知外科醫師
- BAdminister IV calcium gluconate靜脈注射葡萄糖酸鈣
- CPlace the client in high-Fowler's position將病人置於高福勒氏臥位
- DPrepare for emergency tracheostomy✓ 正解準備緊急氣管切開術
— Explanation · 中文詳解 —
甲狀腺術後出現喉鳴音暗示喉頭水腫或血腫壓迫氣管，這是氣道危及生命的緊急狀況。氣道保護為首要，準備氣管切開術或床邊氣切盤是必須的優先程序。A 處理低血鈣；C 雖然能改善呼吸但不足以應對急性氣道阻塞；D 應由同事協助，護理師需留在床邊。
Laryngeal stridor and respiratory distress four hours post-thyroidectomy suggest laryngeal edema or hematoma compressing the airway, which is a life-threatening emergency. Airway patency is the highest priority; thus, the nurse must prepare for an emergency tracheostomy or bedside airway kit. While notifying the surgeon is necessary, the nurse must first ensure the airway remains open to prevent asphyxiation.
✦ 台美臨床差異
美國醫院通常床邊即備有氣切包（trach set），台灣亦然，但護理師對於啟動氣道救援的授權流程在美制中更具主導性。