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當個案病情惡化且初始照護提供者的回應未能解決安全疑慮時，請依序排列護理措施。

Ordered Response

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Activate the rapid response pathway and next chain-of-command level immediately if the response remains delayed or inadequate 若回應仍延遲或不足，立即啟動快速反應路徑及下一層指揮鏈層級

Document assessment changes, notifications, response times, orders, interventions, and the client's response 記錄評估變化、通知、回應時間、醫囑、處置及個案的回應

Communicate the current findings, urgency, actions already taken, and a clear recommendation using the facility's structured format 使用機構的結構化格式溝通目前的發現、急迫性、已採取的措施，以及明確的建議

Stay with the client, reassess airway and breathing, call for bedside help, and begin permitted emergency measures 留在個案身邊，重新評估呼吸道與呼吸，呼叫床邊協助，並開始被允許的緊急措施

Read back any order, state the unresolved concern explicitly, and set a short reassessment or response deadline 覆誦任何醫囑，明確陳述未解決的疑慮，並設定短暫的重新評估或回應期限

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相同主題的下一題A nurse in a busy emergency department is triaging five clients who arrive simultaneously.…本題收錄於此題庫[전통+신유형] NCLEX LEVEL UP 패키지KRW 79,000

僅供學習參考。實際臨床請遵循最新指引與所屬機構規範。