— 照護管理 · HARD · SATA —
護理師在車禍事故中進行災難分流，哪些病人應被評估為「立即」（紅色標籤）？（選所有適合的）
A nurse is caring for a client with multiple injuries after a motor vehicle accident. Which clients should the nurse triage as 'immediate' (red tag) using the disaster triage protocol? (Select all that apply.)
- AA client with a tension pneumothorax✓ 正解患有張力性氣胸的病人
- BA client with a compound fracture of the femur股骨開放性骨折的病人
- CA client with an unstable airway and respiratory distress✓ 正解呼吸道不穩定且呼吸困難的病人
- DA client with a minor abrasion and minor lacerations患有輕微擦傷與輕微割傷的病人
- EA client with massive hemorrhage that is currently uncontrolled✓ 正解目前未受控制的大出血病人
— Explanation · 中文詳解 —
災難分流（START triage）原則在於用最快時間救治最需要且有機會存活的病人。紅色標籤代表需立即處理的生命威脅，包括氣胸（A）、呼吸道阻塞（C）以及無法止血的嚴重出血（E）。骨折（B）為黃色標籤（延遲處理），擦傷（D）為綠色標籤（輕傷）。
In disaster triage, red-tagged clients require immediate intervention for life-threatening conditions that are treatable. These include tension pneumothorax, airway compromise with respiratory distress, and uncontrolled massive hemorrhage, as these conditions pose an immediate risk of death without prompt care.
✦ 台美臨床差異
美國災難護理訓練普及，RN 常需參與 CERT；台灣護理師在災難救護的實際分流經驗多集中於演習，臨床實際分流流程亦由醫師主導。