— 照護管理 · EASY · MCQ —
護理師在急診進行分流，應優先評估哪位病人？
A nurse is triaging clients in the emergency department. Which client should be assessed first?
- AA 45-year-old with a laceration on the forearm requesting stitches前臂有撕裂傷並要求縫合的45歲患者
- BA 22-year-old with a twisted ankle after playing soccer踢足球後腳踝扭傷的22歲患者
- CA 35-year-old complaining of a fever and productive cough主訴發燒且有產痰性咳嗽的35歲患者
- DA 60-year-old reporting substernal chest pressure radiating to the jaw✓ 正解報告胸骨下壓迫感並輻射至下巴的60歲患者
— Explanation · 中文詳解 —
根據優先順序原則，應優先處理具生命威脅的緊急狀況。胸痛（substernal chest pressure）可能是急性心肌梗塞，屬於必須立即啟動緊急應變程序的高危險症狀。撕裂傷、扭傷及呼吸道感染症狀通常屬於較穩定的非致命性問題，應排在心臟症狀之後評估。
According to triage prioritization principles, the nurse must assess the client with the most life-threatening condition first. Substernal chest pressure radiating to the jaw is a classic sign of a potential myocardial infarction, which requires immediate intervention. Other conditions listed, such as lacerations, sprains, or stable respiratory infections, are less urgent.
✦ 台美臨床差異
美台兩地急診分流原則一致，均以 Triage 五級分流系統判斷優先順序。